COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARp 


HX641 39565 
RC941  .G631883  Treatment  of  disease 


RECAP 


k 


'-'/ 


Columbia  5Knit)ersttp 

CoUege  of  ^tejsiciang  anb  burgeons; 
iCibrarp 


;% 


Price,  |i.5o. 

TREATMENT  OF  DISEASES 


OF   THE 


HEART  AND  LUNGS, 


WITH    OVER 


T" ZT JD  'U'  i:'      ZTTT  7irr\  D  T?T^ A JUTJC^    lr!Jrj^^T7  T 3 


Errata  in  Formulary. 
On  page  Si,  Read :  Syrupi  Sei^egse,  3  i. 

On  page   153,  last  line,  Read :  Dose,  at  bedtime, 
to  a  child  of  ten  years. 


BY 

CHARLES  H.  GOODWIN,  M.  D. 


SECOND  EDITION,  RE  VISED. 


NEW  YORK : 
C.  H.  GOODWIN,  M.  D., 

245  West  5  3D  Street. 
1883. 


Price,  $1.50. 

TREATMENT  OF  DISEASES 


OF   THE 


HEART  AND  LUNGS, 

WITH    OVER 

THREE  HUNDRED  AND  FIFTY  FORMULA  AND 
PRE  SCRIP  TIONS, 

AS   EXEMPLIFIED    IN   THE 

HOSPITALS  OF  NEW  YORK  CITY: 

BELLEVUE,  ROOSEVELT,  ST.  LUKE'S, 

NEW  YORK,  PRESBYTERIAN,  GERMAN, 

CHARITY,  ST.  FRANCIS',  MT.  SINAI. 

IN   THE   SERVICES   OF 

Drs.  Alonzo  Clark,  Austin  Flint,  Alfred  L.  Loomis,  E.  G. 

JANEWAY,  W.  H.  Draper.  F.  Delafield,  W.  H.  Thomson, 

A.  jAcoBi,  J.  R.  Leaming,  a.  H.  Smith,  Beverly 

Robinson,  J.  Lewis  Smith,  G.  G.  Wheelock, 

J.  H.  Ripley,  F.  H.  Bosworth,  A.  C, 

Post,  A.  A.  Smith,  etc.,  etc. 

BY 

CtlARLES  H.  GOODWIN,  M.  D. 


SECOND  EDITION,  RE  VISED. 


NEW  YORK : 
C.  H.  GOODWIN,  M.  D., 

245  West  530  Street. 
188-S. 


I7U 


Copyright. 

By  C.  H.  Goodwin,  M.  D. 

A.D.  1882. 


W.  L.  Mershon  <r<  Co., 

Printers,  Electrotypers  and  Binders, 
Rahway,  N.  J. 


CD 
lO 

CO 


PREFACE. 


The  author  believes  he  is  correct  in  stating,  that 
arrlong  the  numerous  medical  works  there  is  no 
book  which  places  before  the  physician  the  real 
practical  hospital-treatment  of  disease :  treatment 
which,  founded  on  daily  experience  of  the  leading 
medical  men  of  the  times,  and  in  the  great  wards 
of  metropolitan  hospitals,  necessarily  represents  the 
latest,  most  approved,  and  most  successful  methods. 

A  certain  number  of  medical  gentlemen,  from 
various  parts  of  the  country,  visit  this  city  each 
year,  at  no  little  expense  and  loss  of  time,  for  the 
purpose  of  attending  these  hospitals  and  acquaint- 
ing themselves  with  the  views  of  the  prominent  and 
recognized  authorities  connected  therewith.  How 
valuable  such  information  proves  to  them  is  evident 
to  all,  and  beyond  question.  This  practical  knowl- 
edge the  author  has  endeavored  to  place  before  the 
profession. 

The  present  volume  contains  a  resume  of  the 
treatment  of  the  several  diseases  of  the  lungs  and 
heart,  as  exemplified  in  the  various  hospitals  of 
New  York  City.  It  is  hoped  that  the  many  imper- 
fections, of  which  the  author  is  only  too  conscious, 
may  be  dealt  lightly  with,  and  that  the  work  may 
prove  a  useful  one  to  the  practitioner. 


% 


<K0 


J 


CONTENTS. 


PART  I. 

DISEASES  OF  THE  LUNGS. 


PNEUMONIA. 

Definition  (7). — Diversity  of  Treatment  (7). — Treatment  in 
Bellevue  Hospital  :  General  treaiment  (8)  ;  by  Dr.  Alonzo  Clark 
(17)  ;  by  Dr.  A.  L.  Loomis  (20)  ;  by  Dr.  Austin  Flint  (23)  ;  by  Dr. 
W.  H.  Thomson  (31)  ;  by  Dr.  E.  G.  Janeway  (32). — Treatment  in 
N.Y,  Hospital  :  by  Dr.  W.  H.  Draper  (32). — Treatment  in  Pres- 
byterian Hospital:  by  Dr.  A.  H.  Smith  (39);  by  Dr.  A.  C.  Post  (40). 
— Treatment  in  Charity  Hospital  :  by  Dr.  Beverly  Robinson 
(40). — Treatment  in  St.  Luke's  Hospital  :  by  Dr.  J.  R.  Learning 
(41). — Treatment  in  Roosevelt  Hospital  (43). 

PLEURISY. 

Definition  (45). — Treatment  in  Bellevue  Hospital  :  Actde 
Pleurisy — by  Dr.  A.  L.  Loomis  (45)  ;  by  Dr  Alonzo  Clark  (46)  ;  by 
Dr.  Austin  Flint  (46).  Subacute  Pleurisy — by  Dr,  A.  L.  Loomis  (47J  ; 
by  Dr.  Alonzo  Clark  (47)  ;  by  Dr.  Austin  Flint  (49)  ;  by  Dr.  E.  G. 
Janeway  (50) ;  General  treatment  (50).  Empyema — by  Dr.  A  L, 
Loomis  (51);  by  Dr.  Alonzo  Clark  (52);  by  Dr,  W.  H.  Thomson 
(53) ;  by  Dr,  Austin  Flint  (53) ;  by  Dr.  E.  G.  Janeway  (53) ;  by  Dr. 
W.  IM.  Polk  (53)  ;  General  treatment  (54). — Treatment  in  N.  Y. 
Hospital:  Acute  Pleurisy — by  Dr.  W,  H.  Draper (54).  Subactite 
Pleurisy — by  Dr.  W.  H.  Draper  (55),  Ejupyeina — by  Dr.  J.  W. 
McLane(56)  ;  by  Dr.  W.  H.  Draper  (57).  Fibrous  Pleurisy — by  Dr. 
W.  H.  Draper  (57). — Treatment  in  Roosevelt  Hospital  :  Acute 
PleuHsy — by  Dr.  F.  Delafield  (59).  Subacute  Pleurisv — by  Dr.  F, 
Delafield  (60).  Empyema— hy  Dr.  F.  Delafield  (61) ;  by  Dr.  W.  H, 
Draper  (62).  Fibrous  Pleurisy — by  Dr.  F.  Delafield  (62).  Treat- 
ment IN  Presbyterian  Hospital-:  Acute  Pleurisy — General  treat- 
ment (62),  Subacute  Pleurisy — by  Dr.  Hadden  (62).  Etiipyetna — by 
Dr,  Hadden  (63). — Treatment  in  St.  Francis'  Hospital:  Actite 
Pleurisy — by  Dr.  J.  H.  Ripley  (63).     Empyema — by  Dr.  J.  H.  Ripley 


11  CONTENTS. 

(64). — Treatment  in  St.  Luke's  Hospital  :  Acute  Pleurisy — by 
Dr.  C.  W.  Packard  (64).  Empyema—  by  Dr.  C.  W.  Packard  (64)  ; 
by  Dr.  A.  C.  Post (65)  — Treatment  in  Charity  Hospital  ;  Acute 
Pleurisy — by  Dr.  J.  Lewis  Smith  (65).  Subacute  Pleurisy — by  Dr.  J, 
Lewis  Smith  (66)  ;  by  Dr.  Beverly  Robinson  (67).  Empyema — by 
Dr.  J.  Lewis  Smiih  (68). — Treatment  in  Mt.  Sinai  Hospital  : 
Subacute  Pletirisy — by  Dr.  A.  Jacobi  (68).  Empyema — by  Dr.  A. 
Jacobi  (6g). — General  Surge/y  and  Antisepsis  (69). 

HYDROTHORAX— HYDROPNEUMOTHORAX. 

Definition  (71). — Treatment  in  N.  Y.  Hospital  :  Hydrothorax — 
by  Dr.  W.  H.  Draper  (71).  Ilydropneumothorax — by  Dr.  W.  H. 
Draper  (72). — Treatment  in  Bellevue  Hospital  :  HydrotJwrax — 
by  Dr.  A.  L.  Loomis  (72);  by  Dr.  Alonzo  Clark  "(72).  Ilydro- 
pnetimotho7-ax — by  Dr.  A.  L  Loomis  (73)  ;  by  Dr.  Alonzo  Clark  (73)  ; 
by  Dr.  F.  Delafield  (73). 

PULMONARY  PHTHISIS. 
Definition  (74). — Treatment  in  Bellevue  Hospital  :  by  Dr.  A. 
L.  Loomis  (74)  ;  by  Dr.  A.  A.  Smith  (77)  ;  by  Dr.  Alonzo  Clark  (78)  ; 
by  Dr.  Austin  Flint  (82)  ;  by  Dr.  E.  G.  Janeway  (82)  ;  General  treat- 
ment (82). — Treatment  in  Presbyterian  Hospital  :  by  Dr.  F.  A. 
Burrali  (S3);  by  Dr.  A.  H.  Smith  (85).— Treatment  in  N.  Y. 
Hospital  :  by  Dr.  W.  H.  Draper  (85). — Treatment  in  Charity 
Hospital  :  by  Dr.  Beverly  Robinson  (86) ;  by  Dr.  J.  W.  Howe  (90). 
— Treatment  in  Roosevelt  Hospital:  by  Dr.  F.  Delafield  (90). 
— Treatment  in  Mt.  Sinai  Hospital  (92). 

LARYNGEAL  PHTHISIS. 
Definition  (93). — Treatment  in  N.  Y.   Hospital  :    by  Dr.   W. 
H.  Draper  (93). — Treatment  in  Bellevue  Hospital:  by  Dr.  F. 
H,  Bos  worth  (94). 

SPASMODIC  ASTHMA— HAY  FEVER. 
Definition  (97). — Treatment  in  Bellevue  Hospital  :  Spasmodic 
AstJwia — by  r3r.  Alonzo  Clark  (97)  ;  by  Dr.  A.  L.  Loomis  (99);  by 
Dr.  W.  H  Thomson  (100)  ;  by  Dr.  Austin  Flint  (100).  /lay  Fever 
— by  Dr.  Alonzo  Clark  (loi). — Treatment  in  Presbyterian  Hospi- 
tal: by  Dr.  A.  H.  Smith  (loi). — Treatment  inN.Y.  Hospital:  l)y 
Dr.  W.  H.  Draper  (102). — Treatment  in  St.  Francis'  Hospital. 
by  Dr.  J.  H.  Ripley  (103). —  Treatment  in  St.  Luke's  Hospital: 
by  Dr.  G.  G.  Wheelock  (103). —Treatment  in  Mt.  Sinai  Hospital 
(103). — Treatment  in  German  Hospital  :  by  Dr.  A.  Jacobi 
(104). 

BRONCHITIS. 
Definition  (105). — Treatment  in  Bellevue  Hospital  :    Acute 
Catarrhal  Bronchitis — by   Dr.  Alonzo  Clark  (105);  by  Dr   J.  Lewis 
Smith  (106) ;  by  Dr.  A.  L.  Loomis  (107).     Capillary  Bronchitis — by 


CONTENTS.  iii 

Dr.  Alonzo  Clark  (107)  ;  by  Dr.  A.  L.  Loomis  (ro8)  ;  General  treat- 
ment (108).  Chronic  Bronchitis — by  Dr.  Austin  Flint  (109) ;  by  Dr. 
Alonzo  Clark  (109)  ;  by  Dr.  A.  L.  Loomis  (109)  ;  by  Dr.  J.  Lewis 
Smith  (no)  ;  by  Dr.  A.  Jacobi  (in)  ;  by  Dr.  E.  G.  Janeway  (112). 
Plastic  Bronchitis — by  Dr.  Alonzo  Clark  (112)  ;  by  Dr.  A.  L.  Loomis 
(112).  Fetid  Bronchitis — by  Dr.  Alonzo  Clark  (112). — Treatment 
IN  N.  Y.  Hospital  :  Acute  Catarrhal  Bronchitis — by  Dr.  W.  H, 
Draper  (113).  Capillary  Bronchitis — by  Dr.  W,  H.  Draper  (114)  — 
Treatment  in  St.  Luke's  Hospital  :  Acute  Catarrhal  Bronchitis — 
by  Dr.  J.  R.  Learning  (115).  Chronic  Bfonchiiis—hy  Dr.  A.  H. 
Smith  (115);  by  Dr.  Beverly  Robinson  (115). — Treatment  in  Mt. 
Sinai  Hospital  :  Chronic  Bronchitis — by  Dr.  A.  Jacobi  (116). — 
Treatment  in  Charity  Hospital  :  Capillary  Bronchitis — by  Dr. 
Beverly  Robinson  (117). 

EMPHYSEMA. 

Definition (ii3). — Treatment  in  Bellevue  Hospital:  by  Dr. 
Austin  Flint  (118)  ;  by  Dr.  Alonzo  Clark  (119)  ;  by  Dr.  A.  L. 
Loomis  (120). — Treatment  in  Presbyterian  Hospital  (121). — 
Treatment  in  N.  Y.  Hospital  :  by  Dr.  W.  H.  Draper  (121). — 
Treatment  in  Roosevelt  Hospital:  by  Dr.  F.  Delafield  (122). 

PULMONARY  H/EMORRH AGE— CONGESTION- 
APOPLEXY. 

Definition (124). — Treatment  in  N.  Y.  Hospital:  by  Dr.  W. 
H.  Draper  (124). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
Alonzo  Clark  (125)  ;  by  Dr.  A.  L.  Loomis  (126). — Treatment  in 
Charity  Hospital:  Dr.  Beverly  Robinson  (127);  by  Dr.  J.  W. 
Howe  (127). 

PULMONARY  CEDEMA. 

Definition  (128), — Treatment  in  Bellevue  Hospital:  by  Dr. 
A.  L.  Loomis  (128) ;  by  Dr.  Austin  Flint  (129). — Treatment  in  N. 
Y.  Hospital  :  by  Dr.  W.  H.  Draper  (129). — Treatment  in  Pres- 
byterian Hospital  :  by  Dr.  A.  H.  Smith  (130). 

PULMONARY  GANGRENE. 

Definition  (131). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
A.  L.  Loomis  (131);  by  Dr.  Alonzo  Clark  (131). — Treatment  at 
Charite  Hospital,  Paris  (132). 


IV  CONTENTS. 


PART  II. 

DISEASES  OF  THE  HEART. 


VALVULAR  LESIONS. 

Definition  (133). — Treatment  in  Bellevue  Hospital:  by  Dr. 
Austin  Flint  (133)  ;  by  Dr.  Alonzo  Clark  (137)  ;  by  Dr.  Fordyce 
Barker  (140);  by  Dr.  A.  L.  Loomis(i4i);  byDr.W.  H.Thomson  (142); 
by  Dr.  E.  G.  Janeway  (144). — Treatment  in  N,  Y.  Hospital  :  by 
Dr.  W.  H.  Draper  (144). — Treatment  in  Presbyterian  Hospetal  : 
by  Dr.  F.  A.  Burrall  (150)  ;  by  Dr.  A.  H.  Smith  (150). — Treat- 
ment IN  Roosevelt  Hospital:  by  Dr.  F.  Delatield  (151). — 
Treatment  in  St.  Luke's  Hospital  :  by  Dr.  G.  G.  Wheelock 
(151), — Treatment  in  Mt.  Sinai  Hospital:  by  Dr.  A.  Jacobi 
(152). 

PERICARDITIS. 

Definition  (154). — Treatment  in  Bellevue  Hospital:  by  Dr. 
Alonzo  Clark  (154)  ;  by  Dr.  A.  L.  Loomis  (155)  ;  by  Dr.  Austin 
Flint  (156). — Treatment  in  N.  Y.  Hospital:  by  Dr.  W.  H. 
Draper  (157). — Treatment  in  Presbyterian  Hospital  (159). — 
Treatment  in  Charity  Hospital  (159). — Treatment  in  St. 
Francis'  Hospital,  by  Dr.  J.  H.  Ripley  (159). —  Treatment  in 
Mt.  Sinai  Hospital:  by  Dr.  A.  Jacobi  (160). — Treatment  in 
Roosevelt  Hospital  :  by  Dr.  W.  H.  Thomson  (160). 

HYDROPERICARDIUM. 

Definition  (162). — Tre.\tment  in  Bellevue  Hospital  :  by  Dr. 
Alonzo  Clark  (162)  ;  by  Dr.  A.  L.  Loomis  (163). 

ENDOCARDITIS. 

Definition  (164). — Treatment  in  N.  Y.  Hospital  :  by  Dr.  W. 
II.  Draper  (164). — Treatment  in  Bellevue  Hospital:  by  Dr. 
Austin  Flint  (164)  ;  by  Dr.  Alonzo  Clark  (165)  ;  by  Dr.  A.  L. 
Loomis  (165). 

HYPERTROPHY  OF  THE  HEART. 

Definition  (167). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
A,  L.  Loomis  (167). — Treatment  in  N.  Y.  Hospital  :  by  Dr.  W. 
H.  Draper  (168). — Treatment  in  Mt.  Sinai  Hospital:  by  Dr. 
A.  Jacobi  (168).  u 


CONTENTS.  V 

DILATATION  OF  THE  HEART. 

Definition  (169). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
Alonzo  Clark  (169)  ;  by  Dr.  A.  L.  Loomis  (170). — TREATMENT  IN 
Roosevelt  Hospital  :  by  Dr.  W.  H.  Thomson  (172). 

FATTY  DEGENERATION  OF  THE  HEART. 

Definition  (174). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
Alonzo  Clark  (174);  by  Dr.  A.  L.  Loomis  (175);  by  Dr.  Austin 
Flint  (175). 

PALPITATION. 

Definition  (177). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
Austin  Flint  (177)  ;  by  Dr.  A.  L  Loomis  (178)  ;  by  Dr.  Alonzo 
Clark  (179);  by  Dr.  E.  G.  Janeway  (179), — Treatment  in  St. 
Luke's  Hospital:  by  Dr.  Beverly  Robinson  (180). — Treatment 
IN  N.   Y.   Hospital  :  by  Dr.  W.  H.  Draper  (182). 

ANGINA  PECTORIS. 

Definition  (184). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
Austin  Flint  (184)  ;  by  Dr.  Alonzo  Clark  (185)  ;  by  Dr.  A.  L. 
Loomis  (185). — Treatment  in  N.  Y.  Hospital  :  by  Dr.  W.  H. 
Draper  (186). 

ANEURISM  OF  THE  AORTA. 

Definition  (188). — Treatment  in  Bellevue  Hospital  :  by  Dr. 
A.  L.  Loomis  (188)  ;  by  Dr.  Austin  Flint  (189)  ;  by  Dr.  Alonzo 
Clark  (190). — Treatment  in  N.  Y.  Hospital  :  by  Dr.  W.  H. 
Draper  (191);  by  Dr.  C.  E.  Hackley  (192);  by  Dr.  T.  M.  Markoe 
(194). — Treatment  in  Roosevelt  Hospital  ;  by  Dr.  F.  Delafield 
(194). — Treatment  in  St.  Luke's  Hospital  :  by  Dr.  G.  G. 
Wheelock  (195). — Treatment  in  Presbyterian  Hospital  :  by 
Dr.  A.  H.  Smith  (195). — Treatment  by  Ligation  of  Carotids  : 
by  Dr.  John  A.  Wyeth  (195). 


PART  I. 
DISEASES  OF  THE  LUNGS. 


PNEUMONIA. 

Definition. — Inflammation  of  the  substance  of 
the  lungs,  which,  in  its  typical  form,  runs  a  definite 
course,  characterized  by  sudden  invasion  of  the 
usual  symptoms  of  inflammatory  fever,  attended 
with  a  rapid  and  considerable  elevation  of  tempera- 
ture which  maintains  its  height  until  a  period  be- 
tween the  fifth  and  eighth  or  tenth  day,  correspond- 
ing to  commencing  convalescence,  when  it  may  as 
suddenly  fall,  while  the  local  lesion  is  still  at  its 
maximum  of  intensity.  The  course  of  the  disease 
is,  moreover,  modified  by  the  general  condition  of 
the  patient  and  by  complications. 

There  is  perhaps  no  disease,  at  the  present  day, 
the  treatment  of  which  has  been,  and  is,  attended 
with  more  diversified  plans,  each  of  which,  moreover, 
has  its  own  measure  of  reputed  success.  Bleeding, 
the  calomel  treatment,  tartar  emetic,  quinine,  alco- 
hol, the  cold  pack,  etc.^  are  all  employed.  Again, 
in  contradistinction,  some  regard  all  medication  as 

7 


8  PNEUMONIA. 

of  little  or  no  significance  whatever.  In  support  of 
this  latter  view,  rapid  and  complete  recovery  has 
been  observed  in  cases,  severe  as  well  as  otherwise, 
double  pneumonias  as  well  as  single,  where,  without 
the  administration  of  a  particle  of  medicine,  the 
treatment  has  been  simply  good  nursing,  perfect 
rest,  and  careful  feeding.  That  each  method,  how- 
ever, is  not  applicable  to  all,  but  is  peculiarly  service- 
able in  certain  cases,  or  in  certain  conditions,  there 
can  be  no  question.  Calomel  has  saved  life  when 
every  other  possible  effort  had  failed.  Blood-letting 
would  hardly  be  employed  at  the  onset  in  an  elderly 
or  asthenic  patient.  Cold  would  not  be  applied 
injudiciously. 

Believing  this,  then,  does  it  not  follow :  that  while 
the  various  plans  of  treatment  are,  all  of  them,  sev- 
erally useful,  none  are  specific  ;  no  one  must  be  con- 
sidered as  sufficient,  or,  on  the  other  hand,  required 
in  every  case  of  whatever  nature ;  but  that  the  par- 
ticular adaptation  of  each  resort,  and  its  serviceabil- 
ity, depends  essentially  upon  the  indications  called 
for  and  the  conditions  existing  in  each  individual 
instance  ;  and  that  every  measure  has  proven,  and 
does  possess,  its  own  value,  every  means  its  own 
degree  of  merit,  when  suitably  applied  and  with  dis- 
crimination. 

BELLEVUE  HOSPITAL. 

Before  proceeding  to  the  more  detailed  remarks 
the  treatment  adopted  at  this  hospital  will  be  con 
sidered  first  from  a  general  standpoint. 


PNEUMONIA.  9 

No  routine  plan  is  employed  for  all  cases.  The 
patient  is  placed  on  a  good  nourishing  diet,  consist- 
ing usually  of  milk  and  eggs,  and  absolute  rest  in  bed 
in  the  recumbent  position  enforced.  The  general 
indications  for  treatment  are  to  sustain  the  vital 
powers  and  to  keep  the  temperature  within  due 
bounds  until  the  disease  has  run  its  course.  To  ful- 
fill the  former,  stimulants  are  administered,  the  pulse 
being  considered  as  the  best  indication  of  the  powers 
of  resistance  ;  an  increase  in  its  frequency  and  dimin- 
ished force  requiring  stimulation.  For  this  purpose 
wJiiskey,  3  ss.  every  three  hours,  is  usually  given, 
alternating  or  in  conjunction  with  ammonitim  car- 
bonate, grs.  V.  every  three  hours,  according  to  indica- 
tions. Digitalis  is  also  used  considerably  for  this 
object,  and  in  some  instances  camphor.  If  there  is 
much  pain  present,  morphine  is  given  to  relieve  it ; 
or  sometimes  a  coat  of  iodine  is  ordered.  Occa- 
sionally the  oil-silk  jacket  is  applied.  If  the  patient 
is  seen  at  the  onset  of  the  disease,  aconite  is  given 
in  some  instances.  Spirit  of  mindererus,  sweet  spirit 
of  nitre,  calomel,  and  Dover's  powder  are  also  used 
at  times  in  the  early  stage.  For  the  high  tempera- 
ture quinine  is  very  generally  employed,  usually 
beginning  with  quinice  snlph.  grs.  x-xv.  thrice  daily, 
and  increasing  or  diminishing  the  amount  according 
to  the  fever.  Or,  when  met  in  the  first  stage,  grs. 
XX.  of  quinine  are  given,  followed  by  doses  of  grs. 
X.  three  times  daily. 

For  hypodermic  administration,  the  following 
solution  is  often  employed  at  this  hospital :     • 


lO  PNEUMONIA. 

]^.     Quiniae  sulph.     .         .  .         grs.  Ixxx. 

Aquae     .  .  .  .  A.    3  i. 

Acid  sulphur,  dil.  .  q.  s. 

Heat  to  boiling,  and  add : 

Acidi  carbol.  .  .  grs.  v. 

M. 

In  some  cases  the  sponge-bath  is  used  in  combina- 
tion. When  the  temperature  rises  to  102°  or  103"^, 
a  sponge-bath  occupying  fifteen  minutes  is  given, 
and  repeated  as  often  as  necessary  ;  with  this,  qtiinicE 
sulph.,  grs.  xv-xx.  are  administered  internally  and 
often  very  effectually.  In  many  instances,  however, 
cold  alone  is  employed,  in  the  form  of  the  wet-pack. 
When  cough  is  very  distressing,  the  hypodermic 
injection  of  sol.  morpJiic2  siilpJi.  {Magejidic),  M.  v- 
viiiy  generally  affords  relief.  If  there  is  much  laryn- 
geal cough  and  pain,  poultices  applied  to  the  neck 
are  found  very  serviceable.  When  the  dyspnoea  is 
marked,  with  a  sense  of  suffocation,  quebracho  is 
often  of  great  benefit ;  also  in  some  cases  associated 
with  pleurisy,  where  the  respirations  are  quick  and 
very  labored,  two  or  three  doses  have  given  relief 
lasting  for  several  hours.      It  is  administered  thus : 

9.      Ext.  quebracho  fl.     .         .  .  3  ss. 

Sig.     Dose,  every  three  or  four  hours,  or  p.  r.  n. 

Should  pulmonary  cedema  develop,  rapid  and 
repeated  dry  cupping  is  applied,  and  tincture  of 
digitalis  gtt.  x-xx.  given,  together  with  ammonium 
carbonate,  and  whiskey,  in  doses  of  5  ss.  hypodermic- 
ally.  These  measures  are  repeated  if  the  oedema 
returns.     In  other  cases  wet  cups  are  used,  drawing 


PNEUMONIA.  II 

blood  to  '^x-xii.     Or  sometimes  the  hot-pack  and 
oxygen  are  resorted  to. 

When  the  heart's  action  is  strong  and  the  pulse 
rapid, 

9.     Tine,   aconiti  rad.    .  .         .         gtt.  i. 

Aquae  q.  s. 

M.  Sig.  Dose,  every  hour. 
is  given  until  its  effects  begin  to  be  manifest.  In  cer- 
tain instances  bleeding  is  employed  in  the  early  stage. 
In  young  sthenic  patients  where  the  full  effect  of  the 
febrile  movement  is  shown  by  a  full,  strong  pulse, 
restlessness,  and  a  tendency  to  delirium,  it  is  believed 
that  quinine  is  not  needed  ;  general  blood-letting  is 
often  resorted  to,  and  the  entire  condition  of  the  case 
made  more  comfortable.  Or,  the  patient  is  put  under 
the  influence  of  aconite,  as  above,  combined  with 
small  doses  of  opium,  with  the  same  beneficial 
effect. 

In  mild  cases,  where  the  only  indication  for  treat- 
ment is  a  feeble  pulse,  whiskey  is  given  in  ^  ss.  doses 
every  one,  two,  or  three  hours  as  demanded.  This, 
with  a  milk  diet  and  absolute  rest  and  quiet  in  recum- 
bency, is  all  that  is  required.  Or,  where  the  general 
condition  of  the  patient  is  good,  vital  signs  good, 
and  no  special  call  for  medication,  the  patient  is  sim- 
ply ordered  a  diet  of  milk  and  eggs,  combined  with 
rest  in  bed.  No  medicinal  treatment  whatever  is 
employed.  In  others,  morphia  may  be  needed  to 
relieve  the  pain,  and  digitalis  for  the  heart. 

In  more  severe  cases,  where  the  previous  condition 
of  the  patient  has  been  bad,  and  there  is  much  dys- 


12  PNEUMONIA. 

pnoea,  with  cerebral  symptoms,  dry  tongue,  and  high 
fever,  stimulants  are  given  as  required,  together  with 
quinicE  sulph.,  grs.  xx-xl. 

Morphia  is  also  administered  for  the  pain,  and 
Hoffman's  anodyne,  or  sweet  spirit  of  nitre,  with 
digitalis  for  the  heart's  action.  If  the  pulse  becomes 
very  weak  and  irregular,  and  cardiac  failure  is  immi- 
nent, ammonium  carbonate,  grs.  v.  are  immediately 
given,  alternating  every  fifteen  minutes  with  spts. 
frtunenti,  5  •^•^•>  arid  repeated  as  necessary. 

Owing,  however,  to  the  previous  bad  habits  and 
poor  condition  of  many  of  the  patients,  the  treat- 
ment of  pneumonia  often  resolves  itself  into  treat- 
ment of  the  exhaustion,  oedema  of  the  lungs,  etc. 
Many  cases  are  similar  to  the  following.  The  patient 
is  a  tolerably  healthy  man  in  the  early  stage  of  the 
fever,  with  a  temperature  of  104°,  and  respiration 
50;  pulse  good  and  condition  quite  comfortable.  A 
milk  and  ^^<g  diet  is  ordered,  together  with  qiihmte^ 
grs.  XV.  This  corresponds  to  the  morning.  During 
the  afternoon  the  patient  grows  weak,  slightly  cyan- 
osed,  and  respiration  is  accelerated.  Moist  rales, 
both  coarse  and  fine  are  heard,  and  oedema  is  begin- 
ning to  develop.  Dry  cups  to  the  number  of  one 
hundred  or  more  are  at  once  applied,  and  the  oedema 
disappears.  The  following  is  administered :  Tinct. 
digitalis^  m.  x.  every  three  Jioiirs,  and  ivJiiskey  zss. 
every  two  Jiours  ;  together  with  milk  and  eggs.  Under 
this  treatment  the  patient  improves,  until  toward 
evening,  when  the  oedema  again  appears.  Cupping 
is  resorted  to,  and  anmionium  carb.,  j;rs.  x.  given  e\'er7 


PNEUMONIA.  13 

two  hours,  alternating  with  the  whiskey,  and  the 
oedema  is  again  relieved.  Inhalation  of  oxygen  is 
also  ordered  for  the  night,  to  be  inhaled  fifteen  min- 
utes during  every  hour.  This  relieves  the  dyspnoea, 
but  toward  morning  the  cyanosis  and  oedema  recur. 
Cupping  is  again  applied,  and  whiskey,  "^ss.  every 
hour,  administered,  alternating  with  carbonate  of 
ammonmin,  grs.  x.  every  hour. 

By  this  means  the  patient  is  carried  through  the 
night,  and  in  the  morning  feels  much  easier.  Milk 
and  eggs  are  still  given.  The  patient  is  not  allowed 
to  sleep  continuously  at  any  time,  for  it  is  during 
sleep  that  the  oedema  shows  itself.  Thus,  by  prompt 
and  energetic  measures,  continued  as  often  as  indi- 
cated, the  greatest  reliance  being  placed  on  whiskey, 
milk,  and  dry  cupping,  the  crisis  is  not  infrequently 
tided  over.  If,  however,  the  case  becomes  still  worse, 
various  means  of  treatment  are  resorted  to.  Other 
forms  of  ammonia  are  used  ;  hypodermic  injections 
of  camphor  dissolved  in  sweet  oil  are  given  every 
three  hours  in  doses  of  grs.  iv.  If  persistent  oedema 
is  present,  w^ith  a  full  pulse,  blood-letting  is  practiced, 
and  is  of  excellent  service  when  digitalis  and  cupping 
fail.  Hypodermic  injections  of  ether,  up  to  3  i-ii, 
sometimes  bring  up  the  pulse.  Champagne  given  in 
doses  of  3  i  every  five  minutes  is  of  service  in  the 
crisis.  Stimulation  has  its  limit ;  if  3  ss.  doses  of 
whiskey  repeated  every  half-hour  has  no  effect,  there 
is  no  benefit  derived  by  increasing  the  amount,  unless 
an  alcoholic  preservation  of  the  stomach  is  desired 
at  the  autopsy. 


14  PNEUMONIA. 

In  complicated  cases  where  the  pain  and  constitu- 
tional symptoms  are  severe,  and  the  vital  signs  show 
high  temperature  with  frequency  of  pulse  and  respi- 
ration, the  treatment  is  necessarily  of  grave  import- 
ance. The  following  is  an  interesting  illustration, 
because  of  the  severity  of  the  case  and  its  complica- 
tions. 

The  patient,  aet.  14,  in  previous  good  health,  was 
admitted  to  the  hospital  on  the  20th.,  with  pulse 
145,  respiration  48,  and  temperature  \o^l°^  The 
attack  was  sudden,  sharp,  and  the  constitutional  dis- 
turbance very  marked.  Face  flushed,  respiration 
panting  with  moaning,  and  pain  in  the  side  intense. 
Cough  painful,  and  sputa  viscid  but  not  rusty.  Con- 
solidation was  present  in  the  lower  lobe  of  the  right 
lung.  The  indications  for  treatment  were  considered 
to  be  to  sustain  the  vital  forces  and  to  relieve  the 
pain. 

^.     Sol.  morph.  sulph.  (U.S.P.)         .  3  ss. 

Spts.   frumenti    .         .         .         .  3  ii- 

Sig.  Dose, 
were    given,  and  the  patient   placed   on  a  milk  diet 
with  absolute  rest  in  bed.     The   pulse  shortly  after- 
ward fell  to  120,  and  the  respiration  to  44.     At  5  P.  M., 
the  following  was  administered  : 

]^.     Tinct.  digitalis    ....         m.v. 
Spts.  frumenti    .         .         .         .  3  ii- 

Sig.  Dose. 

At  6.30  P.  M.,  the  pulse  was  120,  and  respiration 
42.  Whiskey  and  morphia  repeated  as  above,  with 
milk.     8  P.  M.,  P.  104,  R.  40,  T.  105.° 


PNEUMONIA.  15 

1^.     Spts.  trumenti     .         .         .         .  3ii- 

Sig.  Dose,  every  three  hours, 
given  with  milk.     10  P.  M.,  P.  120,  R.  40. 

2 1  St. — A.  M.,  P.  123,  R.  44,  T.  104.5°.  Patient 
complains  of  pain,  and  moans  with  each  respiration 
unless  kept  under  the  influence  of  morphia.  Takes 
milk  freely  and  does  not  vomit.  Whiskey  continued, 
as  above,  every  two  hours.  12  M.,  P.  130,  R.  36.  2 
P.  M.,  P.  130,  R.  40.  3.15  P.  M.,  P.  120,  R.  38,  T. 
105°.  Complains  of  pain,  and  Zss.  of  morphia  solu- 
tion {U.S. P.)  given.  5  P.  M.,  P.  122,  R.42.  7  P.  M., 
P.  109,  R.  40.  Patient  somewhat  delirious.  Admin- 
istered sol.  morph.  sulph.  {U.  S.  P.),  Zi-  10  P.  M.,  P. 
112,  R.  34.     Patient  asleep  and  perspiring. 

22nd. — 7.30  A.  M.,  T.  104.5°.     Ordered: 

9.     Spts.  frumenti  ...  3  ii- 

Spts.  ammon.  aromat      .         .         gtt.  x. 

Sig.  Dose,  every  two  hours. 

9.20  A.  M.,  P.  120,  R.  48.  Patient  takes  milk  and 
eggs  freely.  M.  v.  of  Magendie  s  solution  given 
hypodermically.  2  P.  M.,  P.  120.  R.  35,  T.  103.5°. 
Ordered : 

9.     Spts.  frumenti     .         .         .         .  3  ii- 

Tinct.  digitalis     ....        m.x. 

Sig.  Dose,  every  two  hours, 
and  hypodermic  of  Magendie  repeated.  4.35  P.  M., 
P.  128,  R.  32,  T.  103°.  8  P.  M.,  P.  120,  R.  33,  T.  103°. 
Whiskey  and  aromatic  spirits  of  ammonia  given 
every  hour.  Ice  and  carbonic  acid  water /r^  re  nata. 
9.  P.  M.  Retention  of  urine  and  catheter  employed. 
P.  118,  R.  34.    Morphine  to  relieve  the  pain. 


l6  PNEUMONIA. 

2ird. — 3  A.  M.,  p.  112,  R.  36.  Tongue  dry  and 
patient  rational.  Injection  of  Magendie  repeated 
for  the  pain.  7.30  A.  M.,  P.  109,  R.  33,  T.  103^°. 
Urine  drawn  by  the  catheter.  10  A.  M.,  P.  128,  R. 
30.  First  appearance  of  rusty  expectoration.  Pain 
in  the  side  intense.  Examination  revealed  invasion 
of  the  upper  lobe,  with  consolidation  at  the  apex. 
2.30  P.  M.  Pulmonary  oedema  developed.  Dry  cups 
freely  applied  with  considerable  relief,  and  the 
following  administered : 

5-     Spts.  frumenti  .         .         .  3  ii. 

Tinct.  digitalis  .         .         .  m.x. 

Spts.  ammon.  aromat.       .  .         gtt.x. 

Sig.  Dose,  every  half-hour. 

(The  ammonia  was  given  to  prevent,  if  possible, 
the  formation  of  heart-clot).  4.30  P.  M.  Physical 
signs  of  oedema  disappeared.  Pulse  115.  Whiskey, 
digitalis  and  aromatic  spirits  of  ammonia  repeated 
every  hour.  7  P.  M.,  P.  130,  R.  35.  Patient  com- 
plains of  severe  pains  in  the  side. 

]^.     Sol.  morph.  sulph.  (Magendie)  .         m.v. 
Tinct.  digitalis         .         .         .  m.viii. 

Sig.  Dose,  hypodermically. 
administered ;  also  an  enema  which  produced  free 
evacuation  of  the  bowels  and  of  the  bladder.  8.30 
P.  M.  Slight  pulmonary  oedema  present,  and  m.  x. 
of  tincture  of  digitalis  given  hypodermically ;  also, 
sol.  vwj'pJi.  sulpJi.  {U.S. P.),  3i  by  the  mouth.  10.30 
P.  M.  Evidences  of  oedema  disappeared,  and  res- 
piration 34. 


PNEUMONIA.  17 

2^th. — I  A.  M.  Tincture  of  digitalis  repeated.  3 
A.  M.,  P.   120,  R.  29. 

No  signs  of  oedema.     Ordered  : 

9.     Tinct.   opii    ....         m.xxv. 
Tinct.  digitalis      .  .         .  m.x. 

Sig.   Dose. 

5  A.  M.  Digitalis  repeated.  7.40  A.  M.,  T.  104°. 
8  A.  M.  Digitalis  repeated.  9  A.  M.,  P.  118,  R.  32. 
No  pain. 

On  the  following  day  the  patient  improved,  and 
was  convalescent  in  one  week  ;  the  succeeding  treat- 
ment consisting  chiefly  in  the  administration  of 
nourishment  and  a  moderate  amount  of  alcoholic 
stimulants. 

Dr.  Alonzo  Clark  varies  his  treatment  accord- 
ing to  the  general  condition  of  the  patient.  In  all 
cases  the  importance  of  rest  in  bed  is  insisted  on. 
During  the  first  four  days  the  diet  should  not  be 
forced  ;  after  that  period  he  advises  good,  nourish- 
ing food  to  support  the  strength  for  the  resolution 
and  prostration.  Regarding  medication,  he  finds 
that  many  do  well  on  no  treatment  whatever.  In 
the  early  stage  of  pneumonia,  in  certain  cases,  where 
the  patient  has  been  previously  healthy  and  robust, 
but  never,  in  any  case,  after  the  fifth  or  sixth  day,  he 
practices  bleeding  to  the  extent  of  from  3  iii-iv  to 
5  x-xii.  In  doi'ng  this  he  is  accustomed  to  using  cups, 
after  scarification,  drawing  5  iii-v  of  blood  from  the 
affected  side.  Dr.  Clark  is  not  partial  to  cold  as  an 
antipyretic,  and  strenuously  objects  to  the  applica- 
tion of  ice  to  the  chest.     In  some  instances  he  allows 


1 8  PNEUMONIA. 

the  cold  sponge-bath,  or  a  bath  at  a  temperature 
twenty  degrees  below  that  of  the  patient's  body  ;  a 
bath  of  80°  cooled  down  to  75°,  but  no  lower.  As  a 
rule,  however,  he  considers  the  administration  of 
quinine  the  safest  plan,  given  in  full  doses :  usually 
commencing  in  adult  cases,  with : 

9.     Quiniae  sulph.  .        .         .         grs.x 

Sig.  Dose,  three  times  daily. 

This  amount,  he  finds,  almost  invariably  controls 
the  high  temperature,  and  exhibits  about  all  the 
power  of  the  bath  or  other  external  application. 

Dr.  Clark  also  resorts  to  other  means  of  medica- 
tion according  to  the  demands  of  each  particular 
case.  A  gentle  sweating  is  sometimes  induced  by 
means  of  the  oil-silk  jacket,  with  flannel  beneath  and 
over  it.  Acoftite  is  also  employed  by  him  with  a 
view  of  reducing  the  frequency  of  the  pulse  and  the 
body  heat.  Veratriun  viride  is  considered  unsafe  ; 
his  objection  being  that  when  administered  with  any 
degree  of  freedom,  it  is  very  apt  to  lead  to  collapse. 
He  occasionally,  though  rarely,  uses  tartar  emetic  in 
doses  of  gr.  \-\,  just  suf^cient  to  cause  a  little 
nausea,  and  dew  on  the  forehead.  As  regards  calomel 
in  large  doscs^  it  is  not  a  favorite  with  him,  on  account 
of  the  disastrous  effects  on  the  teeth.  In  one  par- 
ticular instance,  however,  he  accords  the  saving  of 
life  to  the  free  exhibition  of  this  drug,  as  follows : 

5.     Hydrarg.  chlor.  mit.  .         .         .  3  i- 

Sig.  Dose. 

This  was  repeated  three  times  in  the  course  of  the 
day,  and  followed  by  three  or  four  doses  of  3i,  each. 


PNEUMONIA.  19 

Regarding  alcohols,  Dr.  Clark  does  not  place  much 
reliance  upon  them.  As  an  antipyretic,  he  considers 
alcohol  of  but  little  value.  Should  the  pulse  become 
frequent,  small  and  feeble,  a  milk  punch  may  be 
given ;  although,  at  that  stage,  when  the  respiration 
is  obstructed  to  such  an  extent  that  alcoholic  stim- 
ulants are  called  for,  he  thinks  their  benefit  but  tem- 
porary and  not  of  sufficient  amount  to  enable  the 
patient  to  recover.  If,  however,  the  typhoid  condi- 
tion comes  on,  he  administers  alcohol  with  marked 
service. 

In  pneumonia  occurring  secondarily,  his  treat- 
ment is  altogether  supporting  ;  sustaining  the 
patient  with  tonics,  and,  if  indicated,  alcoholic 
stimulation  from  the  onset  of  the  disease.  Bleed- 
ing, either  by  cups  or  leeches,  is  of  course  contra- 
indicated. 

In  chronic,  or  interstitial,  pneumonia  he  orders 
that  the  medical  and  dietetic  treatment  be  made 
in  the  highest  degree  nourishing.  The  patient 
must  be  encouraged  to  take  all  the  food  that 
the  stomach  can  digest,  and  the  strength  otherwise 
supported  by  tonics,  freely  administered.  He  also 
resorts  to  counter  irritation  with  iodine.  Upon  the 
affected  side  of  the  chest,  over  a  space  as  large  as 
the  palm  of  the  hand,  a  coat  of  iodine  is  applied  until 
the  part  becomes  painful ;  then  another  adjoining 
spot  of  about  the  same  size  is  selected,  this  followed 
by  a  third,  and  so  on.  Each  particular  spot  is  painted 
twice  daily  for  three  days,  when  he  usually  finds  that 
it  has  become  sufficiently  irritated. 


20  PNEUMONIA. 

The  following  is  an  excellent  combination  which, 
as  a  tonic,  is  often  used  at  this  hospital : 

^.     Quiniae  sulph.        .         .         .         .     gr.  i. 

Strychniae  sulph.     .         .         .         gr.  -Jg* 

Ferri  phosphat.    .         -.        .         •     gi"*  ii- 
Syrupi     .         .         ...         .         fl.  3  i. 

M.     Sig.     Dose. 

Dr.  Loomis  has  no  established  plan  of  treatment. 
In  many  instances  he  finds  that  rest  in  bed,  with  a 
nutritious  diet,  consisting  of  milk,  eggs,  etc.,  is  all 
that  is  needed.  A  hypodermic  of  morphia  may  be 
given  for  the  pain.  In  severe  forms  of  the  disease, 
however,  he  has  resort  to  other  measures.  For  the 
high  temperature,  in  the  first  stage,  he  places  the 
most  reliance  upon  quinine,  as  follows : 

Ip,.     Quiniae  sulph.         .         .         .     gr.  xx-xl. 
Sig.    This  amount  daily. 

This  almost  invariably  causes  a  marked  reduction 
within  a  short  time.  When  quinia  fails,  however, 
and  the  temperature  remains  high,  the  patient  is 
placed  on  the  water-cot  and  cold  applied  ;  but,  as  a 
rule,  he  finds  the  use  of  cold  dangerous. 

Dr.  Loomis  considers  it  of  the  greatest  importance 
to  detect  the  first  signs  of  commencing  heart  failure, 
as  death  in  the  majority  of  instances  is  due  to  insuffi- 
ciency of  the  heart.  This  he  believes  to  depend 
upon  a  defective  cardiac  nerve  supply,  which  may 
be  due  to  a  morbific  agent  present  in  the  pneumonic 
process.  To  overcome  this  loss  of  nerve  power,  he 
finds  opiuvi  of  greatest  value,  besides  affording  com- 
fort and  relief  from  the  suffering.      Believing  that 


PNEUMONIA.  21 

the  heart  failure,  though  it  may  not  be  apparent,  is 
initiated  at  the  onset  of  the  disease,  or  at  all  events 
at  a  much  earlier  period  than  it  is  usually  manifested, 
his  rule  is  to  bring  the  patient  under  the  full  influ- 
ence of  opium  at  the  commencement  of  the  pneu- 
monia, by  hypodermic  injections  of  morphia,  and  to 
keep- up  a  condition  of  comfort  until  the  period  of 
infiltration  is  completed  ;  usually  for  the  first  four 
days.  After  this  he  advises  great  care  in  its  use, 
otherwise  paralysis  of  the  bronchi  may  follow,  with 
accumulation  of  the  secretions.  By  this  treatment 
he  finds  that  the  chances  of  heart  failure  are  greatly 
lessened,  and  cases  which  from  age  and  other  cir- 
cumstances seemed  hopeless,  have  recovered.  The 
administration  of  opium  in  this  way,  he  advises,  does 
not  interfere  with  the  antipyretic  treatment  of  the 
disease,  nor  does  a  demand  for  alcoholic  stimulation 
contraindicate  its  use. 

As  to  bleedings  Dr.  Loomis  regards  this  procedure, 
even  in  the  strong  and  robust,  as  one  vrhich  tends  to 
retard  convalescence^  and  more  or  less  dangerous. 
In  such  cases,  however,  where  there  is  sudden  con- 
gestion and  oedema,  he  resorts  to  free  venesection 
with  marked  benefit.  In  very  young,  or  elderly,  or 
in  asthenic  patients,  blood-letting  is  contraindicated. 
Antimony  and  calomel  he  discountenances.  In 
regard  to  veratrum  viride  and  aconite,  he  classes 
them  in  the  same  category  with  bleeding.  Where  a 
heart  tonic  is  indicated,  he  prefers  digitalis.  After 
consolidation  has  taken  place,  for  sustaining  the 
heart's   action   alcohol  is   administered,  the   amount 


22  PNEUMONIA. 

being  determined  by  the  state  of  the  pulse ;  usually 
varying  from  3  iv.  to  3  viii-x.  daily.  In  enfeebled 
patients,  however,  alcoholic  stimulants  are  often 
required  from  the  beginning,  while  in  the  young  and 
robust  very  little,  or  frequently  none  at  all,  is  needed. 
He  also  employs  carbonate  of  ainmoniuin,  at  times, 
but  prefers  champagne  for  a  diffusible  stimulant,  as 
the  ammonia  is  apt  to  disturb  the  stomach.  Counter- 
irritation  is  also  resorted  to  when  indicated.  If  pul- 
monary oedema  occurs,  dry  cupping  is  applied  with 
great  benefit.  Occasionally  the  oil-silk  jacket  is 
found  very  beneficial.  During  convalescence  the 
diet  is  made  of  the  most  nutritious  character,  and 
tonics,  tro?i  and  cod-liver  oil  freely  administered.  The 
following  is  the  formula  for  Dr.  LOOMIS'  tonic : 

9.    Quiniae  sulph.         .  .         .     grs.  xxx. 

Acid,  sulph.  dil.  .         .         .           q.  s. 

Aquae     .         .         .  .         .         .       3  ii. 

Tinct.  ferri  chlor.  .         .         .           §  ss. 

Spts.  chloroformi    .  .         .         .      3  vi. 

Glycerinse  q.  s.  ad.  .         .         .            3  iv. 
M.    Dose:  A  teaspoonful. 

In  chronic,  or  interstitial,  pneumonia  he  advises 
that  everything  promoting  nutrition  be  employed 
and  carried  to  the  highest  possible  degree,  together 
with  the  administration  of  those  remedies  which 
serve  to  check  the  further  progress  of  the  disease. 
By  the  use  of  stimulating  inhalations,  such  as 
oleum  terebintJiincE,  he  also  endeavors  to  relieve  the 
tubes  of  their  accumulations  and  so  avoid  their  be- 


PNEUMONIA.  23 

coming  fetid.  If  the  condition  is  due  to  a  bronchitis, 
every  precaution  must  be  taken  to  prevent  attacks 
of  this  character. 

In  Dr.  Austin  Flint's  wards,  patients  with  pneu- 
monia are  not  infrequently  treated  solely  on  the 
expectant  plan,  and  without  the  interference  of 
medicinal  measures.  This  is  particularly  true  of 
mild  attacks  where  the  patient  is  in  robust  health, 
temperate,  and  with  good  history.  He  orders  a  diet 
consisting  of  milk  and  eggs,  or  milk  and  beef-tea,  a 
pint  of  either  being  taken  during  every  four  hours, 
combined  with  rest  in  bed.  A  small  amount  of 
whiskey  is  also  administered  throughout  the  course 
of  the  disease,  according  to  indications.  In  these 
patients  even  where  the  case  has  advanced  to  the 
second  stage  when  first  seen,  the  same  plan  is  pur- 
sued in  many  instances.  Morphia  is  given  for  the 
pain.  If  the  fever  exacerbates,  a  full  dose  of  quinine, 
grs.  x-xx.,  is  given  and  usually  controls  it.  These 
cases  all  go  on  to  recovery  very  favorably  without 
any  medication  whatever,  no  indications  for  positive 
treatment  arising. 

In  severer  forms,  where  there  is  more  or  less  pros- 
tration, pain  and  cough,  with  anorexia,  he  admin- 
isters stimulants : 

5-     Spts.  vini  gall.  .         .         .  fss. 

Sig.  Dose,  every  two  hours. 

together  with  a  milk  diet.  If  the  heart's  action  is 
feeble  and  somewhat  irregular,  he  gives  tiyicture  of 
digitalis,  tn,  xx.  three  times  daily.     Should  diarrhoea 


24  PNEUMONIA. 

come  on,  the  following   is   usually   employed   with 
success : 

]^.    Tinct.  opii     ..... 

Tinct.  capsici    .... 

Spts.  camphorae    .         .         .         .    aa  5  i« 

Chloroformi     ...  3  iii. 

Alcoholis  q.  s.  ad.         .         .         .  5  v. 

M.  Dose  :  twenty  minims. 
Where  the  temperature  is  not  high,  nothing  in  the 
way  of  an  antipyretic  is  resorted  to.  When,  however, 
the  pyrexia  requires  treatment,  he  orders  qiiinice 
sulph.  grs.  xx-xl.  daily,  with  very  marked  benefit. 
If  pulmonary  oedema  supervenes  with  imminent 
danger,  his  resort  is  to  immediate  venesectiofiy  draw- 
ing blood  to  5  x-xii. 

Dr.  Flint  not  infrequently  employs  cold  in  the 
form  of  the  wet-pack,  as  an  antipyretic  in  pneumonia. 
So  far  his  results  have  been  very  favorable.  As  a 
rule,  when  the  fever  reaches  103°  the  pack  is  resorted 
to;  the  body,  nude,  is  wrapped  in  a  sheet  wet  with 
water  at  a  temperature  of  80°  F.,  and  sprinkled  at 
short  intervals  with  water  of  the  same  temperature. 
While  he  does  not  consider  this  procedure  admis- 
sible in  all  instances,  yet  he  believes  that  in  uncom- 
plicated cases  the  patient  may  remain  in  the  wet- 
sheet,  with  sprinkling  of  cold  water,  not  only  without 
danger  but  with  positive  benefit,  until  the  tempera- 
ture has  fallen  two,  three,  or  more  degrees.  He  also 
repeats  the  treatment  with  perfect  safety  whenever 
the  hyperpyrexia  returns.  The  period  required  for 
this  reduction  of  the  fever,  he  finds,  varies  from  one 


PNEUMONIA.  25 

to  several  hours.  On  one  occasion  the  patient 
remained  in  the  wet  sheet  ten  hours.  Sometimes, 
however,  the  temperature  continues  to  fall  after 
removal  from  the  pack  or  bath.  Dr.  Flint  is  also 
inclined  to  think  that  cold  has  a  favorable  influence 
on  the  course  of  the  disease.  In  his  wards  he  has, 
in  some  instances,  treated  exclusively  by  this  anti- 
pyretic measure,  and  many  of  these  cases  recovered 
in  a  shorter  time  than  the  usual  average.  As  a  rule, 
however,  in  addition  to  this  means,  the  patient  is 
put  upon  a  diet  of  milk  and  eggs,  together  with 
whiskey  in  3  ss.  doses  every  two  hours,  especially  if 
addicted  to  its  use.  Ammoniiun  carb.  grs.  v.  every 
two  hours,  are  also  given,  and  morphia  in  sufficient 
amount  to  relieve  the  pain  and  secure  rest.  To  the 
administration  of  quinia  and  ammonium  carbonate, 
in  these  cases,  he  also  attributes  a  certain  amount  of 
influence. 

In  those  cases  where  pulmonary  oedema  exists  in 
a  degree  sufficient  to  cause  much  embarrassment  of 
the  respiration,  Dr.  Flint  resorts  very  successfully 
to  immediate  blood-letting.  The  dyspnoea  which 
remains  he  treats  with  inhalation  of  oxygen  gas.  In 
such  instances,  although  he  does  not  consider  it  a 
positive  contraindication,  yet  he  believes  it  best  to 
err,  if  at  all,  on  the  side  of  caution  ;  therefore  he 
would  not  employ  the  wet  sheet  lest  it  might  do 
harm.  Sponging  of  parts  of  the  body  is,  however, 
resorted  to  with  good  effect.  By  practicing  this  con- 
tinually for  a  long  time,  he  often  accomplishes  all 
that  is  to  be  obtained  by  the  wet-pack  or  the  cold  bath. 


26  PNEUMONIA. 

The  following  cases,  treated  in  Dr.  Flint's  wards 
at  this  hospital,  will  serve  very  effectuall)'  to  illustrate 
these  two  plans  of  treatment,  namely,  blood-letting 
and  cold.  They  are  mentioned  in  full,  with  all  the 
variations  of  temperature  throughout  the  course  of 
the  fever,  in  order  to  exhibit  minutely  the  thera- 
peutical indications,  and  the  effects  of  the  treatment 
prescribed. 

Case  I. — In  this  case  blood-letting  was  employed, 
followed  by  the  sponge-bath  as  an  antipyretic. 

S.  K.,  female,  aet.  23;  domestic  ;  admitted  May 
9th.  Four  days  before  admission,  patient  had  a  well- 
marked  chill,  with  vomiting,  headache,  fever,  and 
pain  under  the  left  nipple.  She  grew  weak,  lost 
appetite  and  all  power  of  exertion,  but  still  kept  at 
work  up  to  time  of  entering  the  hospital.  On 
admission,  temperature  102°,  pulse  120,  and  respira- 
tion 40.  Cheeks  flushed.  Patient  complains  of 
great  weakness  and  of  pain  in  the  left  mammary 
region,  with  cough  and  rusty  expectoration.  Over 
the  lower  lobe  of  the  left  side  there  was  increased 
fremitus,  dulness,  bronchial  breathing,  and  broncho- 
phony. No  rales.  Heart,  abdominal  viscera,  and 
urine  normal.  Patient  was  ordered  whiskey  ^ss. 
every  half  hour,  and  annnonium  carbonate,  grs.  v, 
every  tivo  hours;  together  with — • 

9.    Infus.  digitalis.  .         .         ,  §ss. 


Morph.    Sulph.  .         .         .         gr. 


8* 


Sig.  Dose,  every  three  hours. 

gth. — 3.30    P.   M.,    pulmonary    oedema   developed. 
Vettesection   performed    and    blood    to    5  ^ii    drawn. 


PNEUMONIA.  27 

This  quickly  relieved  the  symptoms  due  to  the 
oedema,  which  became  less  marked,  and  patient's 
general  condition  was  much  improved.  4.30  P.  M., 
temp.  i03-J-°;  ordered  spts,  frwnenti^  Z^^-  ^'^^I'y 
hour.  6  P.  M.,  temp.  104°.  7  P.  M.,  temp.  same.  12 
P.  M.,  temp.  I03i°. 

loth. — 10  A.  M.,  temp.  103^°.  Dyspnoea  intense; 
inhalation  of  oxygen  gas  ordered,  which  gave  relief. 
12  iM.,  temp.  104°.  2  P.  M.,  temp.  104^°.  4  P.  M., 
temp,  same  ;  severe  dyspnoea  ;  gave  oxygen.  6  P.  M., 
temp.    103^°.     8  P.   M.,  temp.  103°.     12  P.  M.,  temp. 

1034°. 

wth. — 9  A.  M.,  temp.  103°.  12  M.,  temp.  104^°. 
2  P.  M.,  temp.  104° ;  considerable  dyspnoea ;  gave 
oxygen.  Ordered  the  patient  sponged  with  tepid 
water,  only  one  extremity  being  exposed  at  a  time. 
4  P.  M.,  temp.  I04i°.  5  P.  M.,  temp.  103°.  7  P.  M., 
temp.  104°.  8  P.  M.,  temp.  103°.  12  P.  M.,  temp, 
same. 

\2th. — 5.30  A.  M.,  temp.  103^°.  9  A.  M.,  temp. 
103J.  II  A.  M.,  temp.  I03f°;  sponge  bath  ordered. 
12  M.,  temp.  ioif°.  3  P.  M.,  temp.  104*^;  sponge 
bath.  3.45  P.  M.,  temp.  102^°.  7  P.  M.,  temp.  104°; 
sponge  bath.     8  P.  M.,  temp.   102°. 

13//^. — I  A.  M.,  temp.  102°.  7  A.  M.,  temp.  ioiJ°. 
9.45  A.  M.,  temp.  101°.  2  P.  M.,  temp.  102°.  5  P.  M., 
temp,  same ;  normal  alvine  evacuation.  7  P.  M., 
temp.  102°.     9  P.  M.,  temp.  101^^°. 

14///. — 8.45  A.  M.,  temp.  99f°.  11  A.  M.,  temp. 
99°.  Patient's  condition  greatly  improved.  Dulness 
on  percussion  diminished ;  respiration  broncho-vesi- 


28  PNEUMONIA. 

cular ;  increased  vocal  resonance,  and  rales  redux  ; 
vocal  fremitus  slightly  increased.  Stimulants  reduced 
to  5  ss.  every  two  hours.  6  P.  M.,  temp.  994°; 
digitalis  discontinued. 

15///.— 8  P.  M.,  temp.  981°;  6  P.  M.,  temp.  99!°; 
carbonate  of  ammonium  stopped,  and  ordered 
whiskey,  3  ss.  three  times  daily. 

\6th. — A.  M.,  temp.  98!°.  P.  M.,  temp.  99°.  Dul- 
ness  now  very  slight.  Broncho-vesicular  breathing 
replaced  by  natural  vesicular  respiration,  and  vocal 
resonance  normal. 

i^th. — A.  M.,  temp.  98J°.  P.  M.,  temp.  g^°. 
Ordered: 

5.     Tinct.  fern  chloridi     .         .         .  gtt.  xx. 
Sig.  Dose,  three  times  daily. 

igth. — A.  M.,  temp.  98^°.  Patient  now  fully  con- 
valescent. Perfect  recovery  took  place  without  any 
perverse  symptoms. 

Case   II. — Treated  by   means  of   the   luet   sheet. 

C.  L.,  male,  aet.  32;  laborer;  admitted  May  i6th. 
The  patient  had  no  regular  occupation  ;  had  wan- 
dered about  the  streets  exposed  to  all  kinds  of 
weather,  and  frequently  remaining  in  wet  clothes  for 
hours.  Four  days  before  admission  he  was  suddenly 
taken  with  severe  chill,  followed  by  fever,  pain  in 
the  right  side,  and  cough.  The  next  day  although 
considerably  weakened,  he  was  on  the  streets  as  usual. 
From  that  time  until  his  entrance  into  the  hospital, 
he  passed  the  days  in  the  park,  and  the  nights  in  a 
cheap  lodging-house.     On  admission,    the  face  was 


PNEUMONIA.  29 

flushed,  dusky,  and  had  an  anxious  expression.  He 
complained  of  cough,  pain  in  the  right  side,  anorexia 
and  weakness.  His  chart  showed  axillary  tempera- 
ture 104°;  pulse  90,  and  strong;  respiration,  26. 
Over  the  lower  and  middle  lobes  of  the  right  lung 
were  dulness,  increased  vocal  fremitus,  bronchial 
respiration  and  bronchophony.  No  rales.  Expec- 
toration rusty  and  adhesive.  Heart,  liver  and  spleen 
normal ;  urine  the  same. 

The  wet  sheet  was  applied,  and  the  patient  left, 
uncovered,  beneath  it  whenever  the  temperature 
reached  103°,  and  was  not  removed  until  the  tem- 
perature of  the  mouth  had  been  reduced  to  102°. 
He  also  had  the  following :  QuinicE  siilph.  grs.  v. 
every  four  hours  together  with  am7noniiiin  carbonate^ 
grs.  V.  every  tJiree  hours. 

i6th. — 5  P.  M.,  temp.  104°;  wet  sheet  applied.  7 
P.  M.,  temp.  101°;  wet  sheet  removed.  9  P.  M.,  temp. 
102^°.     II  P.  M.,  temp.  same. 

lyth. — 2  A.  M.,  temp.  103^^;  the  wet  sheet  was 
applied.  4  A.  M.,  temp.  102°;  wet  sheet  removed. 
8  a.m.,  temp.  ioif°.  10  A.  M.,  temp.  101^°;  pulse, 
90;  respiration,  30.  12  M.,  temp.  101^°.  2  P.  M., 
temp.  102^°.  4  P.  M.,  temp.  103°;  wet  sheet  applied. 
5  P.  M.,  temp.  103^^;  temperature  taken  by  the  rectum, 
the  sheet  being  still  applied.  7  P.  M.,  temp.  I02j°. 
8  P.  M.,  temp.  loi^'';  the  sheet  was  removed. 

i8//^. — 12  P.  M.,  temp.  loi^^.  6  A.  M.,  temp.,  ioof°. 
8  A.  M.,  temp.  loif^.  10  A.  M.,  temp.  loT';  pulse, 
72  ;  respiration,  30.  Over  the  middle  lobe  the  bron- 
chial has  given  place  to  broncho-vesicular  respiration, 


30  PNEUMONIA. 

and  bronchophony  to  increased  vocal  fremitus.  Sub- 
crepitant  rales  are  heard.  The  pneumonia  has,  how- 
ever, invaded  the  upper  lobe,  and  dulness,  bronchial 
breathing  and  bronchophony  extend  upward  nearly 
to  its  apex.  Pleuritic  friction  sounds  are  heard  over 
the  whole  anterior  surface  of  the  lung.  Bronchial 
respiration,  bronchophony  and  crepitant  rales  are 
now  heard  over  the  entire  lower  lobe,  and  over  the 
lower  portion  of  the  upper  lobe.  12  M.,  temp.  I02j°. 
2  P.  M.,  temp.  102^^°.  4  P.  M.,  temp.  101°.  8  P.  M., 
temp.  ioif°. 

\<^th. — 12  P.  M.,  temp.  102°.  4  A.  M.,  temp.  ioiJ°. 
8  A.  M.,  temp.  ioof°;  pulse  full,  72  ;  respiration,  24. 
10  A.  M.,  temp.  1004^°.  At  the  right  apex,  anteriorly, 
respiration  is  now  broncho-vesicular.  Behind,  the 
signs  are  the  same  as  on  yesterday.  12  M.,  temp. 
ioif°.     6  P.  M.,  temp.  ioii°. 

20tJi. — 8  A.  M.,  temp.  \o\\°.     8  P.  M.,  temp.  100.° 

2\st. — A.  M.,  temp.  98^°. 

22nd. — Temperature,  A.  M.,  98^° ;  P.  M.,  98^°. 
Over  the  lower  lobe,  and  over  the  lower  por- 
tion of  the  upper  lobe,  bronchial  respiration  and 
bronchophony  are  less  marked.  Friction  sounds 
and  crepitant  rales  still  heard  over  both  lobes, 
anteriorly. 

24///. — Temperature  normal.  The  respiratory  mur- 
mur, over  the  affected  lobes,  is  now  broncho-vesicular 
in  character,  and  bronchophony  has  been  replaced  by 
slightly  increased  vocal  resonance.  Patient  sits  up, 
and  his  appetite  is  excellent. 

2()tJi. — Resolution    complete,   and    physical    signs 


PNEUMONIA.  31 

normal.  Slight  dulness  still  exists  over  the  lower 
lobe,  referred  to  pleuritic  thickening. 

June  2)d. — Patient  discharged,  entirely  recovered. 

Dr.  W.  H.  Thomson  places  the  patient  on  a  milk 
diet,  together  with,  in  ordinary  cases,  whiskey,  5  2^2- 
daily. 

He  also  prescribes  the  following : 

]^.    Ammon.  carb.        .         .         .      grs.  Ixxx. 

Mucilag.         .... 

Aquae     .         .         .         .         .,       aafl.  5i. 

Spts.  vini  gallici     .         .         .  fl.  3  ii. 

M.    Sig.    A  tablespoonful  three  times  daily. 

When  indicated,  he  alternates  this  with  the  follow- 
ing expectorant : 

]^.     Syrup  scillae  CO.     .         .         .         .       3  iii- 

Vini  ipecac.  ....      3  iss. 

Morph.  sulph.         ....     gr.ss. 

Aquae    ......§  iss. 

Syrupi  q.  s.  ad.      .         .         .         .       §  iv. 
M.    Sig.    A  tablespoonful  three  times  daily. 

The  good  effect  of  these  is  often  promptly  and 
markedly  shown.  Where  the  dyspncea  becomes 
severe,  with  signs  of  increasing  exhaustion,  feeble 
heart  action,  etc.,  he  increases  the  amount  of  stimu- 
lants to  5  xii  daily,  and  orders  in  addition  : 

9-     Infus.  digitalis     .         .         .         .  3ii. 

Sig.   Dose,  every  three  hours. 

In  some  cases,  where  dulness  is  present  over  more 
or  less  of  the  lung,  he  prescribes  ammonium  muriate, 
grs.  XX.  three  times  daily  with  great  advantage. 


32  PNEUMONIA. 

Dr.  E.  G.  Janeway  confines  the  patient  to  bed, 
on  a  milk  diet,  and  for  the  high  temperature  gives : 

5-     Quinias  sulph.     ....     grs.  x. 
Sig.  Dose,  three  times  daily. 

With  this  he  also  administers  stimulants  as  indi- 
cated, and  morphia  in  doses  sufBcient  to  relieve  the 
pain. 

NEW   YORK   HOSPITAL. 

The  patient  is  placed  on  a  milk  diet,  combined 
with  rest  in  bed.  Dr.  W.  H.  DRAPER  considers  that 
the  importance  of  absolute  rest,  in  the  treatment  of 
pneumonia,  cannot  be  over-estimated,  and  that  to 
obtain  it  the  most  stringent  rules  should  be  enforced. 
This,  he  believes,  is  not  recognized  as  much  as  it 
should  be  in  the  treatment  of  diseases  in  general, 
more  especially  acute  affections  ;  and  that  it  may  be 
considered  possible  for  a  patient  of  good  constitu- 
tion to  pass  through  a  course  of  pneumonia  and 
recover,  without  the  use  of  a  single  drop  of  medi- 
cine, provided  he  have  absolute  rest.  In  a  great 
many  instances  his  treatment  is  altogether  support- 
ing and  entirely  on  the  expectant  plan,  so-called ; 
complete  rest  and  antipyretics  forming  the  chief 
means.  Yet  he  does  not  consider  it  strictly  expect- 
ant, since  the  heart's  action  is  carefully  watched  and 
the  fever  controlled. 

In  regard  to  bleeding,  Dr.  DRAPER  objects  to 
such  a  procedure.  Tartar  emetic  is  also  discounte- 
nanced,     poultices,  and  the  oil-silk  jacket   he  con- 


PNEUMONIA.  33 

siders  as  very  uncomfortable  to  the  patient,  and  do 
no  good. 

On  admission,  the  patient  is,  as  a  rule,  put  upon 
alcohol,  digitalis,  and  quinine  ;  these  are  increased  in 
amount  at  night,  and  diminished  during  the  day. 
The  following  is  the  formula  for  the  hypodermic 
solution  of  quinine  used  at  this  hospital  : 

^.     Quini^  sulph.            .         .  .  grs.  clx. 

Ac.    hydrobrom.  (Squibbs)  .  fl.   3  i- 

Spts.  frumenti            .         .  .  ad  fl.  3  i. 

M.  Ft.  solut. 

Mild  cases,  he  repeatedly  finds,  require  no  medi- 
cine whatever,  and  do  perfectly  well,  making  excel- 
lent recovery  with  careful  nursing,  judicious  feeding, 
and  proper  attention  to  the  maintenance  of  the  vital 
powers. 

In  severer  forms,  however,  the  indications  are 
mainly  to  lower  the  temperature  and  support  the 
heart.  For  an  antipyretic,  alcohol  is  employed,  or, 
at  times,  quinia  also.  The  amount  of  alcohol 
required  for  this  purpose  is  of  course  varied.  In 
ordinary  cases  he  administers  bra?idy,  §  t  every  th7'ee 
hours.  But  in  severe  cases  large  doses  are  needed. 
When  the  fever  is  at  its  highest, 

5.     Spts.  vini  gallici  .         .         .      Jxviii. 

are  not  infrequently  given  during  the  day  ;  as  a  result, 
the  pulse  grows  steadier  and  firmer  and  the  temper- 
ature falls  within  bounds.  After  defervescence  is  estab- 
lished, this  quantity  is  reduced  to  §  xii-viii.  or  less. 
Dr.  Draper  finds  this  method  of  treatment  almost 
3 


34  PNEUMONIA. 

invariably  successful.  In  some  instances,  seen  in  the 
first  stage,  with  high  fever,  he  orders  quinice  sidpJi. 
grs.  X.,  tJirice  daily.  This,  in  combination  with  the 
careful  administration  of  alcohol,  has  very  high  value 
in  reducing  the  temperature.  By  the  use  of  quinine 
he  also  obtains  marked  service  in  controlling  the 
nervous  exhaustion.  When  pain  is  prominent,  opium 
is  given  in  sufficient  amount  to  relieve  it. 

To  assist  the  heart  in  overcoming  the  breathing 
obstruction,  stimulants  are  required.  For  this  pur- 
pose Dr.  Draper  administers  digitalis  and  brandy, 
as  follows : 

!^.     Spts.  vini  gallici     .         .         .         .        3  i.       * 

Tine,    digitalis         .         .  .  gtt.  x. 

Sig.  Dose,  every  two  hours. 

Where  signs  of  extreme  exhaustion  are  present,  he 
considers  that  vigorous  stimulation  is  demanded 
(brandy  being  preferred)  up  to  the  time  of  expected 
defervescence.  If  heart  failure  becomes  evident, 
aininoniiun  cm'bonate  and  digitalis  are  administered 
freely.  Especially  in  such  cases,  he  advises,  it  is  to 
be  remembered  that  the  vitality  of  the  patient  is  at 
its  lowest  in  the  early  morning,  reaching  its  mini- 
mum between  the  hours  of  three  and  four ;  hence 
during  the  night  the  indication  for  stimulants  is  con- 
sequently stronger.  Where  there  is  a  condition  of 
restlessness,  opium  is  given  with  advantage.  If 
insomnia  is  prominent,  Dr.  Draper  employs  digi- 
talis, either  alone  or  with  opium,  and  finds  that  by 
diminishing  the  irritability  of  the  respiratory    centre 


PNEUMONIA.  35 

its  effect  is  of  marked  benefit.  He  prefers  it  in  com- 
bination with  opium,  the  result  being  usually  better 
than  from  either  drug  alone.  When  nausea  is  very 
troublesome  the  food  is  given  in  small  quantities  and 
at  short  intervals  with  excellent  effect.  Should  pul- 
monary oedema  or  congestion  occur,  prompt  and  effi- 
cient counter-irritation  is  resorted  to  by  means  of 
dry  cups,  or  sometimes  turpentine  stupes,  together 
with  cardiac  stimulation  ;  the  more  diffusible  stimu- 
lants, such  as  ammonia  and  alcohol,  being  employed. 
This  is  usually  a  source  of  great  relief.  He  also  uses 
small  doses  of  morphia,  atropine,  or  digitaline,  with 
good  effect  ;  cautioning,  however,  that  as  a  cardiac 

stimulant  the  dose  of  morphia  must  be  small  •  he 
gives : 

5--     Sol.  morphise  sulph.  (Magendie)  gtt.  iv-vi. 
Sig.  Dose. 

This  may  be  repeated  in  two  or  three  hours  if  nec- 
essary. Or  morphia  and  digitalis  is  given  in  combi- 
nation. The  extremities  must  also  be  kept  warm. 
Inhalation  of  oxygen  is  at  times  advised  and  fre- 
quently with  very  satisfactory  effect ;  that  is,  the 
immediate  result  is  beneficial  and  the  patient  feels 
greatly  relieved.  By  these  urgent  measures  he  is 
often  enabled  to  tide  over  the  critical  period.  In  all 
cases,  however,  Dr.  Draper  advises  that  the  occur- 
rence of  oedema  be  more  carefully  appreciated,  as 
this  condition  does  not  always  receive  the  attention 
which  its  emergency  demands.  When  the  pneumo- 
nia is  accompanied  by  pleurisy,  count er-ir r it atio7i  is 


36  PNEUMONIA. 

applied  in  the  form  of  iodine  or  blisters  over  the 
affected  part ;  and  if  much  prostration  is  present,  he 
prescribes  the  following : 

]^.     Spts.  vini  gallici  .         .         .         .  §  i. 

Ammon.  carb.       ....  grs.  v. 

Infus.  digitalis      .         .         .         .  3  i. 
Sig.  Dose,  every  hour. 

In  regard  to  diet,  Dr.  DRAPER  considers  milk  the 
best  article  of  food.  He  finds  that  while  patients  of 
acute  disease  may  suffer  from  want  of  food,  yet,  as 
a  rule,  they  are  over-fed,  and  he  believes  that  a  little 
judicious  starving  in  disease  is  better.  Nor  should 
the  wishes  of  the  patient  be  consulted  in  the  choice 
of  food.  The  diet  should  be  taken  in  small  quantity 
and  be  of  the  most  nutritious  quality,  consisting  of 
milk,  animal  broths,  etc.,  but  not  of  solid  food  of  any 
kind.  A  milk  diet  he  considers  the  best  in  the  great 
majority  of  cases,  but  where  this  cannot  be  taken  for 
so  long  a  period,  animal  broths  may  be  given.  These 
however,  he  directs,  must  be  fluid,  concentrated,  and 
rich  in  all  the  elements  of  animal  fibre ;  not  merely 
the  solution  of  a  few  salts  with  extractive  matters. 
He  strongly  urges  that  the  tendency  to  fill  up  with 
''  sick-pap,"  farinaceous  food,  gruels,  etc.,  be  abolished 
as  especially  bad,  setting  up  fermentative  dyspepsia 
and  often  causing  serious  complication.  Sweets  are 
usually  disgusting  to  the  sick  and  must  also  be  abol- 
ished. Dr.  Draper  believes  that  feeding  is  ofttimes 
of  the  greatest  significance,  and  while  the  age,  diges- 
tive powers,  etc.,  must  be  taken  into  consideration, 


PNEUMONIA.  37 

yet  he  thinks  there  is  no  more  important  duty  than 
to  insist  upon  the  most  absolute  strictness  regarding 
the  kind,  quality,  and  amount  of  food  for  the  pa- 
tient. 

In  regard  to  antipyretics  in  pneumonia,  Dr. 
Draper's  views  are  worthy  of  earnest  consideration. 
He  advises  that  in  simple  pyrexia,  where  the  tempera- 
ture does  not  attain  a  very  high  degree,  antipyretics 
should  not  be  pushed  to  any  extreme  resort ;  mild 
cases  should  be  fed  judiciously  and  carefully  watched, 
waiting  on  nature.  But  in  all  high  grades  of  fever 
active  and  vigilant  interference  is  demanded,  for  with 
each  degree  of  reduction  the  danger  is  correspond- 
ingly lessened.  Hence  to  control,  to  reduce  the  tem- 
perature every  twenty-four  hours  the  average  degree 
of  the  fever  is  the  most  essential  feature  ;  if  this  is 
not  done  the  patient  dies  from  simple  exhaustion. 
Quinia,  he  finds,  though  valuable  as  an  antipyretic  is 
not  always  to  be  relied  on.  When  of  specific  service, 
it  owes  its  power  to  an  effect  on  the  essential  cause 
of  the  fever,  as  in  malaria,  surgical  fever,  etc.  The 
same  may  be  said  of  salicylic  acid,  and  in  pneurnonia 
with  previous  history  of  rheumatism,  he  has  fre- 
quently found  this  drug,  in  doses  of  grs.  xx.,  more 
efficient  than  quinine.  The  use  of  cold  in  the  form 
of  the  bath,  pack,  etc.,  he  considers  at  least  a  coura- 
geous procedure,  requiring  great  care  and  judgment, 
and  should  hardly  be  resorted  to. 

In  regard  to  alcohol  as  an  antipyretic,  Dr.  DRAPER 
places  the  utmost  reliance  upon  its  administration  in 
all  high  grades  of  temperature  from  any  cause,  and 


3B  PNEUMONIA. 

believes  there  can  be  no  question  of  its  utility.  It  is 
an  antipyretic,  in  that  it  does  reduce  the  tempera- 
ture ;  while,  at  the  same  time,  it  stimulates  and  sup- 
ports the  heart  and  also  supplies  something,  a  food, 
out  of  which  force  is  eliminated  for  the  vital  func- 
tions. The  fever  is  simply  the  using  up  of  the  pa- 
tient, the  consumption  of  organic  life.  Alcohol, 
being  very  unstable  and  combustible,  is  oxydized  and 
split  up  by  the  fever  into  its  elements,  H^O  and 
CO2  ;  thus,  by  liberating  its  power  and  furnishing  a 
food  which  is  easily  appropriated,  it  supplies  the  force 
which  the  patient  loses  in  heat,  and  so  saves  exhaus- 
tion from  the  combustion  of  his  tissues  and  lessens 
the  animal  heat. 

The  feeding  of  the  fever,  therefore,  Dr.  DRAPER 
constitutes  one  of  the  most  important  elements  of 
the  treatment.  For  this  purpose  alcohol  as  a  food 
is  most  easily  disintegrated,  and  yields  most  readily 
its  power.  This  action  of  alcohol  he  considers  of 
specific  value,  not  only  in  pneumonia,  but  in  all 
fevers  and  at  all  ages.  It  also  stimulates  the  nerve 
centres  ;  the  heart  becomes  more  steady  and  firm,  and 
the  respiration  diminishes  in  frequency  and  gathers 
more  force.  The  quantity  to  be  administered  he 
finds  varies  with  the  patient  ;  there  is  no  law  any 
more  than  with  opium.  In  all  cases  it  is  important 
that  the  temperature  fall,  and  the  pulse  become  less 
frequent,  until  regulated  from  one  twelve  hours  to 
another;  hence  he  gives  it  until  the  desired  effect  be 
obtained.  In  this  connection  he  calls  attention  to 
its  almost  utter  impossibility   to   intoxicate  in  high 


PNEUMONIA.  39 

fever;  for  when  consumed  like  any  other  food  this 
action  is  not  shown.  Therefore  large  quantities  may 
be  taken,  even  a  quart  of  brandy  in  twenty-four 
hours,  without  any  of  the  usual  symptoms  of  alco- 
holism, or  any  odor  upon  the  breath.  When  these 
signs  are  present,  however,  alcohol  is  then  circulating 
in  the  blood  as  alcohol,  and  is  doing  harm  ;  its 
administration  is  then  diminished  or  stopped  alto- 
gether. The  amount  required  ranges  from  §  iv.  to 
5  xxiv.  daily,  usually  5  xii.  to  ^  xviii.  For  adminis- 
tration brandy  is  preferred,  given  with  the  food. 

Dr.  Draper  also  considers  it  important  to  bear  in 
mind  the  influence  of  alcohol  under  circumstances 
where  the  patient  has  become  habituated  to  its  use. 
In  these  subjects,  even  in  mania  a  potu,  with  high 
fever  and  weak  and  feeble  pulse,  the  fever  requires 
food  and  the  heart  must  be  sustained ;  therefore 
he  finds  alcohol  necessary,  and  the  sudden  with- 
drawal of  it  is  often  followed  by  wild  and  active 
delirium. 

PRESBYTERIAN  HOSPITAL. 

To  control  the  high  temperature,  qiiinme  is  given 
in  doses  amounting  to  grs.  xxx-xl.  daily.  For  sus- 
taining the  heart's  action  digitalis  is  employed. 
When  the  pain  is  intense,  one  or  two  leeches  are 
applied  to  the  affected  side,  drawing  blood  to  3  ss-i. 
with  most  beneficial  effect.  For  the  dyspnoea  Dr. 
A.  H.  Smith  finds  that  fluid  extract  of  quebracho j 
m.  xx-xL,  often  affords  marked  relief.     The  following 


40  PNEUMONIA. 

is  his  method  of  administering  quinine  by  inunction, 
especially  serviceable  in  children: 

5.     Quiniae  sulph.       .         .         .         .  3  i- 

Acid,  oleic    .         .         .         .         .  1 1- 

Olei  oliv.      .         .         .         .         .         §  ii. 

Dissolve  the  quinine  in  the  acid  by  the  aid  of  a 
gentle  heat,  and  add  the  oil.  The  solution  should 
remain  clear. 

Sig.  For  inunction,  to  be  well  rubbed  in. 

In  regard  to  bleeding,  Dr.  A.  C.  POST  believes  that 
when  the  lancet  is  properly  employed,  and  with  care- 
ful discrimination,  it  is  the  great  remedy  in  this  dis- 
ease, and  that  recovery  follows  more  rapidly.  He 
does  not  by  any  means  apply  this  rule  to  all  cases,  or 
to  all  stages  of  the  disease  ;  but  only  in  the  com- 
mencement, not  later,  and  in  young,  robust,  and 
healthy  subjects.  When,  however,  consolidation  has 
taken  place,  he  would  never  resort  to  blood-letting. 

The  following  formula,  original  with  this  hospital 
and  very  extensively  employed,  is  recommended  as 
of  marked  value  in  preventing  the  tinnitus  aurium 
and  lessening  the  unpleasant  effects  of  quinine: 

5,.     Potass,  bromid.  .         .         .         grs.  clxii. 
Acid,  tartaric.      .  .         .     grs.  cxcviii. 

Quinine  sulph.     .         .         .         .  3  i- 

Aquai  .....         3  iii. 

M.  et  filt. 

CHARITY  HOSPITAL. 
For  the  fever,  and   especially  where  the  tempera- 


PNEUMONIA.  41 

ture  remains  high,  Dr.  Beverly  Robinson  gives 
large  doses  of  quinine  (grs.  xl).  But  in  cases 
dependent  on  cardiac  disease  and  with  moderate 
fever,  if  the  heart  becomes  weak  and  irregular,  the 
respiration  panting  and  labored,  and  the  general 
symptoms  alarming,  he  stops  the  quinine  and  gives 
digitalis  in  large  doses  with  great  benefit.  When 
there  is  also  a  condition  of  anaemia,  he  administers 
tonics,  together  with  a  most  nourishing  diet, 
moderate  doses  of  quinine,  and  stimulation  to  the 
extent  indicated.  If  oedema  develops,  dry  cups  are 
resorted  to.  The  following  tonic  mixture  is  very 
much  used  at  this  hospital : 

]^.     Cinchonise  sulph.  .             grs.  xxx. 

Acid,  sulph.  dil.  .         .         .       q.  s. 

Aquae          .          .  .           ,         fi.  5  i. 

Acidi  citrici      •     .  .         .         .       3  ss. 

Syrupi           .          .  .         .       fl.  §  iss. 

Tinct.    ferri   chlor.  .         .         fl.  3  ss. 

Aquae  q.  s.  ad.          .  .         .        fl.  §  iv. 
M.     Dose :     A  teaspoonful. 

ST.  LUKE'S  HOSPITAL. 

Dr.  J.  R.  Leaming  is  a  strong  advocate  of  the 
calomel  treatment.  He  considers  it  as  a  remedy 
which  may  be  held  in  reserve  when  all  others  fail. 
The  effect  is  rapid,  and  in  many  instances  he  finds 
that  a  patient  falls  to  sleep  in  a  very  short  time,  who 
prior  to  the  administration  had  been  restless  and 
unaffected  by  anodynes.     By  this  medication  he  fre- 


42  PNEUMONIA. 

quently  obtains  a  controlling  effect  on  the  heart's 
action  and  a  reduction  of  temperature  directly, 
although  the  full  effects  and  benefit  of  the  drug  may 
not  be  had  within  twenty-four  hours.  On  this  plan 
he  gives  full,  sedative  doses,  thus : 

5-.     Hydrarg.  chlor.  mit.     .  grs.  xx-xxx. 

Sig.  Dose. 

according  to  circumstances.  These  large  doses, 
when  indicated,  he  holds  to  be  not  only  harmless  but 
necessary,  in  order  that  the  reparative  process  may 
continue  after  the  internal  inflammation  is  subdued  ; 
this  action  he  claims  as  a  special  result  of  large  doses. 
He  gives  the  drug  in  the  dry  state,  placing  it  upon 
the  tongue,  and  there  leaving  it.  The  after  treat- 
ment consists  in  supporting  and  building  up  the 
strength  of  the  patient  by  good  food,  milk,  eggs, 
etc.  The  following  case  from  his  observation  is 
given  as  an  excellent  illustration  of  this  plan  of  treat- 
ment. 

J.  R.  L.,  physician,  set.  58,  in  good  health.  At  11 
A.  M.,  Nov.  i6th,was  taken  with  a  prolonged  chill. 
At  I  P.  M.,  examination  revealed  crepitant  rales  in 
the  lower  half  of  the  left  lung,  posteriorly,  together 
with  dull  pain.  Temperature,  at  this  time,  i05|°  ; 
pulse  160;  respiration  40. 

J^.     Hydrarg.  chlor.  mit.        .         .     grs.  xxx. 

Sig.  Dose. 

This  amount  was  given  at  once,  placed  upon  the 
back  of  the  tongue.  Temperature  immediately 
commenced  to  fall  until   at  7  P.   M.  when  it  reached 


PNEUMONIA.  43 

99°.  Before  lo  P.  M.  a  second  chill  supervened,  after 
which  the  temperature  again  rose  to  104^°. 

xjtli. — A  third  chill  occurred  before  noon,  followed 
by  a  rise  in  temperature  to  105°,  with  advance  of 
physical  signs.  Above  dose,  calomel  grs.  xxx.  was 
repeated,  and  again  the  fever  began  to  fall.  At  3 
P.M.,  temp.  104°.  5.15  P.M.,  temp,  103°.  8.25  P.M., 
temp.  102°. 

i8//^. — A.  M.,  temp.  ioii°.  During  the  day  the 
temperature  again  exacerbated  to  104°,  with  slight 
increase  of  the  rales  on  the  right  side.  After  this 
the  temperature  did  not  rise  above  101°,  and  on  the 
seventh  day  perfect  defervescence  took  place. 

In  this  case  relief  was  almost  immediate,  the 
patient  being  sensible  of  it  within  half  an  hour.  No 
uncomfortable  feelings  whatever  were  caused  by  the 
calomel.  Indeed,  Dr.  Leaming  thinks  it  would 
possibly  have  been  better  had  the  entire  drachm 
been  given  at  once.  This  heroic  treatment  is,  of 
course,  not  followed  by  him  in  all  instances.  In 
less  severe  forms  of  the  disease,  where  the  tendency 
is  to  recover,  mild  measures  only  are  adopted. 

ROOSEVELT   HOSPITAL. 

To  preserve  the  strength  of  Magendie's  solution  of 
morphia,  the  following  combination  is  used  with  per- 
fect success : 

9^      Morphise  sulph.     .         .         .    grs.  cclvi. 
Acid,  salicylic.         .         .         .  grs.  v. 

Aquae  destil.  •         .         .      fl.  3  xvi. 


44  PNEUMONIA. 

Dissolve  the  salts  in  the  water,  previously  heated 
to  the  boiling  point,  and  filter. 

By  this  method,  also,  the  solution  does  not  change 
or  become  flocculent.  The  combination  was  origin- 
ally formulated  by  Dr.  H.  M.  Keyes  of  this  hospital. 

For  the  hypodermic  use  of  morphia  with  atropia 
the  following  is  employed : 

5.     Morphiae  sulph.  (Magendie).         .  5  i. 

Atropiae    sulph.  .  .  •     gr.  ss. 

M. 

Digitaline  is  administered  hypodermically  thus  : 

^.     Spts.  frumenti    .         .         .         .  §  i. 

Digitalin.   .  .  .  .  .     gi**  ss. 

M.     Sig.  Twenty  minims. 


PLEURISY, 


Definition. — An  inflammation  of  the  serous 
membrane  which  Hnes  the  cavity  of  the  chest  and 
covers  the  contained  viscera;  expressed  by  acute,  lan- 
cinating pain,  usually  confined  to  one  side,  dyspnoea, 
and  a  short,  dry  cough.  The  normal  secretion  of  the 
pleura  is  at  first  arrested,  then,  becoming  increased 
in  amount,  may  accumulate  until  it  ultimately  fills 
the  corresponding  sac  ;  it  is  also  changed  in  quality 
and  may  finally  become  purulent. 

BELLEVUE  HOSPITAL. 

Acute  Pleurisy. — Dr.  Loomis  requires  that  the 
patient  have  complete  rest  in  bed,  and  a  good  nutri- 
tious diet  be  provided.  Blood  letting  and  all  deplet- 
ing measures  are  avoided.  Anodyne  poultices  are 
applied  to  the  chest  and  morphia  given  to  relieve  the 
pain,  injected  hypodermically  over  the  seat  of  inten- 
sity. This  he  finds  of  greatest  benefit.  Where 
anaemia  is  present  iron  is  administered,  thus: 

]^.     Syrup,  ferri  iodidi         .         .         .  3i. 

Sig.  Dose,  three  times  daily. 

In  the   latter  stages    stimulants    are    sometimes 

45 


46  PLEURISY. 

employed  together  with  tonics,  especially  if  recovery 
is  delayed  from  an  excessive  amount  of  effusion 
present. 

Dr.  Alonzo  Clark  resorts  to  prompt  antiphlo- 
gistic measures  to  prevent  abundant  effusion.  Cups 
with  scarifications  are  applied  to  the  affected  side, 
and  repeated  two  or  three  times  after  proper  inter- 
vals. When  the  pain  has  subsided  he  employs  blis- 
ters to  overcome  whatever  inflammation  remains. 
He  finds  no  occasion  for  diuretics,  but  considers  dia- 
phoretics very  serviceable  in  the  later  stages.  Fomen- 
tations of  warm  water,  or  anodyne  poultices,  are  also 
used  with  good  effect.  The  constitutional  treatment 
he  considers  of  little  consequence,  as  a  rule  almost 
none  being  required. 

In  mild  cases,  presenting  at  this  hospital,  where 
the  area  of  plastic  effusion  is  small,  a  smart  blister 
applied  over  the  part  has  marvelous  effect  in  reliev- 
ing the  pain  and  accompanying  distress,  and  promot- 
ing absorption  of  the  effused  material. 

Dr.  Austin  Flint,  as  a  general  rule,  does  not 
resort  to  diuretics  or  hydragogues  to  diminish  th  j 
fluid.  He  considers  them  not  only  unnecessary  in 
many  instances,  but  believes  that  they  impair  the 
strength  of  the  patient  and  impede  recovery. 
Where  the  patient  is  of  good  constitution,  with  good 
inheritance  and  no  pulmonary  trouble,  and  where 
there  is  every  ground  for  favorable  prognosis,  his 
treatment  is  mostly  on  the  expectant  plan.  He 
administers  tonics  with  nutritious  diet,  applies  iodine 
to  !;he  chest,  or  frequently  a  blister,  and  gives    mor- 


PLEURISY.  47 

phia  to  relieve  the  pain  and  afford  rest.     The  follow- 
ing tincture  of  iodine  is  used  at  this  hospital: 

]^.    lodinii       .....  5  ijss. 

Potass,  iodidi    .         .         .         .  5  ss. 

Alcoholis  (75  per  cent.) .  .  §  xvi. 

M. 

A  little  effusion  may  remain  for  some  time,  but  will 
finally  be  disposed  of  by  nature.  Unless  the  fluid  is 
so  abundant  as  to  cause  intense  dyspnoea,  the  aspir- 
ator is  not  employed. 

Subacute  Pleurisy. — Dr.  Loomis  seldom  uses 
any  extreme  diuretic  measures,  cathartics  or  blisters. 
The  nutrition  of  the  patient  is  increased  to  the 
highest  by  means  of  iron,  tonics,  etc.,  giving: 

5-     Syrup,  ferri  iodidi     .  .  .  .31. 

Sig.  Dose,  every  three  hours. 

Combined  with  a  full  and  nourishing  diet.  Under 
this  plan  of  treatment  absorption  is  promoted,  and 
the  most  satisfactory  results  obtain.  In  regard  to 
drawing  off  the  fluid,  when  it  is  abundant  he  resorts 
to  early  aspiration.  Also,  after  the  effusion  has 
remained  at  a  stand-still  for  one  week  ;  or,  especially 
if  the  pleural  cavity  is  greatly  distended,  thus  ob- 
structing the  vessels  and  preventing  absorption,  aspi- 
ration is  employed.  For  this  purpose  Dr.  Loomis 
objects  to  the  needle,  in  aspirating,  as  dangerous  ;  it 
may  injure  the  visceral  pleura  or  the  pericardium, 
and  he  therefore  prefers  to  use  the  trocar  and  canula. 

To  subdue  the  local  inflammation  Dr.  Clark 
advises  the  application  of  blisters,  three  being  usu- 


48  PLEURISY. 

ally  a  sufficient  number.  He  selects  three  points 
over  the  chest,  applying  one  blister  at  a  time;  the 
second  and  third  not  being  used  until  the  spot  of 
the  former  application  has  healed.  Active  diuretics 
are  then  employed.  He  usually  gives  potassi2un 
iodide,  grs.  xxx  tJir ice  daily. 

Should  this  fail  to  lessen  the  amount  of  the  fluid, 
he  makes  use  of  the  following: 

Vji.     Potass,  acetat. 

Infus.  digitalis   .         .         .     aa  3  hi — iv. 
M.     Sig.     This  amount  daily. 

Or  a  diuretic  pill,  combined  as  follows,  is  greatly 
favored  by  him : 

9-.    Pulv.  digitalis. 

Pulv.  scilte. 

Hydrarg.  chlor.  mitis     .         .         aa  gr.  i. 
M.  ft.  pil.  No.  i. 

Sig.  Dose,  three  times  daily. 

When  the  constitutional  effects  of  mercury  are 
prominent,  he  then  returns  to  potassium  iodide.  In 
some  cases  of  highly  nervous  women,  the  milder 
counter-irritants,  such  as  ammoniacal  liniment,  are 
employed ;  but,  as  a  rule,  Dr.  Clark  has  little  faith 
in  them.  Cathartics  are  also  used  at  times,  and  the 
steam  bath  when  indicated.  If  all  these  means  fail, 
the  aspirator  is  resorted  to.  He  objects  to  the  early 
use  of  the  trocar,  however,  unless  forced  to  do 
so,  from  danger  of  the  serous  effusion  becoming 
purulent. 


PLEURISY.  49 

In  simple,  uncomplicated  cases,  Dr.  FLINT  does 
very  little  in  the  way  of  medication.  He  orders  good 
nourishment,  and  employs  counter-irritation  by  means 
of  blisters  or  iodine  (not  infrequently  for  the  patient's 
satisfaction),  and  occasional  mild  diuresis ;  at  the 
same  time  restricting  the  patient  in  the  use  of  the 
upper  limbs,  and  avoiding  all  violent  exercise.  When 
the  effusion  is  reduced  to  a  minimum,  he  usually 
finds  that  nature  takes  care  of  the  remainder.  In 
more  urgent  cases,  to  diminish  the  fluid  the  adminis- 
tration of  hydragogues  and  diuretics  are  employed. 
For  a  diuretic  he  very  often  prescribes  : 

!^.     Potass,  acetat.       .         .         .  .      3  ss. 

Infus.  digitalis       .  .  .  .      §  ss. 

M.     Sig.  Dose,  every  four  hours. 

In  addition  to  this,  olei  tiglii  gtt.  ii.  are  given. 
Sinapisms  or  belladonna  plasters  are  also  applied  to 
the  chest  for  relief  of  the  pain.  Tonics,  iron  and 
quinine,  are  administered,  and,  when  indicated,  small 
doses  of  cod-liver  oil,  together  with  alcoholic  stimula- 
tion. Where  fever  is  present  with  exacerbations  and 
more  or  less  night-sweats,  dyspnoea,  cough,  etc.,  the 
fever  is  controlled  by  quinine,  and  sulphuric  acid  is 
given  to  relieve  the  sweating.  In  regard  to  aspira- 
tion, Dr.  Flint  prefers  the  trocar  and  canula,  as  he 
believes  that  the  sharp  point  of  a  needle  is  apt  to 
injure  the  visceral  pleura  and  to  scratch  the  lung. 
In  withdrawing  the  fluid,  as  soon  as  the  patient  com- 
plains of  any  sense  of  oppression  about  the  chest,  the 
flow  is  immediately  stopped. 

4 


3  iiss. 
5  iii. 

gtt.  XX. 

gtt.  xviii. 


SO  PLEURISY. 

The  following  cod-liver  oil  mixture  is  often  used 
at  this  hospital : 

9-    01.  morrhuae         ....      3  xvi. 
Liquor  potassae    . 
Mellis 

Pulv.  acacise 
01.  anisi 
01.  menthae  vir. 

M.      Dose:  A  tablespoonful. 

Dr.  E.  G.  Janeway  also  objects  to  the  needle  as 
dangerous.  In  cases  of  pleurisy  associated  with 
bronchitis,  where  there  is  great  .dyspnoea  and  cyan- 
osis, he  applies  repeated  dry  cupping  to  the  chest, 
and  administers  digitalis  and  brandy  hypodermically. 

In  some  cases,  at  this  hospital,  such  as  are  occa- 
sionally met  with  in  patients  of  chronic  alcoholism, 
where  the  natural  sensations  have  been  more  or  less 
perverted  by  the  excessive  use  of  alcohol,  when  there 
is  almost  entire  absence  of  rational  symptoms,  no 
cough  or  dyspnoea,  and  very  little  pain,  the  repeated 
application  of  blisters  is  very  often  attended  by  rapid 
disappearance  of  the  fluid. 

In  all  cases  it  is  considered  very*  important  to 
remove  the  fluid,  if  possible,  early  in  the  history  of 
the  disease,  with  a  view  to  preventing  its  change  to 
purulent. 

When  diuretics  are  needed,  the  following  are  used 
in  many  of  the  wards : 

Jji.     Infus.   digitalis  .  .  .      §  ss. 

Potass,  acetat.      .  .  .  grs.  xii. 

M.     Sig.   Dose,  every  three  hours. 


PLEURISY.  51 

Or, 

1^,     Potass,  bicarb.  .         .         .         grs.  xxx. 
Infus.  scoparii    .         .         .         .         5  ss. 
M.     Sig.   Dose,  every  three  hours. 

Sometimes  jaborandi  exerts  a  very  marked  effect 
on  the  effusion.  It  is  given  in  doses  just  sufficient 
to  keep  up  a  free  action  of  the  skin  and  kidneys ; 
usually  thus : 

5.      Ext.  jaborandi  fl        .         .         .         3  ss. 
Aquae  .  .  .  .  .         q.  s. 

M.     Sig.   Dose,  three  times  daily. 

This  drug,  however,  is  not  found  reliable  in  all 
cases. 

Empyema. — When  the  fluid  has  become  purulent 
its  immediate  removal  is  indicated.  For  this  purpose 
Dr.  Loomis,  as  v.  rule,  employs  aspiration  at  inter- 
vals of  three  or  four  days.  The  system  is  thoroughly 
supported  by  good,  nutritious  food,  tonics,  iro7t  and 
qui?ii7ie,  together  with  the  administration  of  stimu- 
lants and  cod-liver  oil  when  needed.  If  practicable, 
he  also  advises  a  change  of  climate.  In  empyema 
occurring  with  blood-poisoning,  a  free  opening  is 
made  in  the  chest,  the  pus  evacuated,  and  the  cavity 
washed  out  with  a  weak  carbolic  acid  or  other 
antiseptic  solution. 

The  following  prescription  is  one  of  Dr.  Loomis' 
tonics,  used  at  this  hospital : 

5-     Sol.  quinise  sulph.     .    (gr.  xv.-^i)      S  ii- 
Tinct.  ferri  chlor.       .         .  .  ^ss. 


52  PLEURISY. 

Spts.  chloroform.         .         .         .        3vi. 
Glycerinae  q.  s.  ad.       .         .         .        '^iv. 
M.   Dose  :  A  teaspoonful. 

Dr.  Clark  first  tries  the  common  means  em 
ployed  in  the  treatment  of  subacute  pleurisy.  If 
these  fail  he  finds  but  one  resource,  nd.me\y,  pimcfitre 
of  the  chest.  Where  an  aspirator  or  pump  cannot  be 
obtained  his  practice  is  to  incise  the  skin,  plunge  in  a 
trocar  and  canula  and,  after  withdrawing  these  instru- 
ments, insert  into  the  opening  thus  made  a  linen  tent, 
fastening  this  by  its  free  ends  to  the  chest  by  means 
of  adhesive  strips.  The  tent  is  removed  every  day  or 
two,  to  allow  the  pus  to  run  out.  Dr.  Clark  is, 
however,  partial  to  the  aspirator  with  a  fine  trocar, 
thus  avoiding  the  use  of  the  scalpel. 

Before  introducing  the  needle  he  always  benumbs 
the  part  by  firm  pressure  with  the  fingers.  The  pis- 
ton is  worked  slowly,  the  fluid  being  drawn  until 
oppression  is  felt  at  the  sternum.  He  advises  cau- 
tion  against  drawing  off  too  much  at  any  one  time, 
for  fear  of  creating  a  vacuum  too  great  for  the  com- 
fort of  the  patient.  In  front  the  operation  is  per- 
formed between  the  sixth  and  seventh  ribs  to  avoid 
wounding  the  diaphragm  ;  on  the  side  the  opening 
is  made  between  the  seventh  and  eighth,  and  in  the 
back  between  the  eighth  and  ninth  ribs.  In  regard 
to  the  injection  of  iodine  for  the  prevention  of  fur- 
ther effusion  of  the  pus,  Dr  Clark  thinks  this  pro- 
cedure is  attended  with  more  harm  than  good.  If 
injections  are  to  be  used  at  all,  he  prefers  simple 
warm  water.     The  strength  of    the  patient  is  sus- 


PLEURISY.  53 

tained  throughout  by  tonics,  good  nourishment,  etc. 
The  aspiration  is  repeated  as  often  as  necessary. 

The  following  is  Dr.  W.  H.  Thomson's  tonic 
formula,  which  is  very  extensively  employed  at 
Bellevue :  s^   y  r^^V^'"-'^ 

]^.    Ferri  et  ammon.  cit.         .         . 
Ammon.  carb. 
Tinct.  gentian,  co. 

Tinct.  quassiae  .         .         .        aa  J  ii. 

Syrupi.  .  ...  5  iss. 

Aquse  q.  s.   ad.  .         .         .         §  viii. 

M.     Dose:  A  dessertspoonful. 

Dr.  Flint  also  employs  aspiration.  In  those  in- 
stances, however,  where  after  finding  pus  at  the  first 
tapping,  and  upon  introducing  the  needle  or  trocar 
at  each  succeeding  period  no  pus  is  obtained,  he 
advises  that  the  operation  be  abandoned  and  the 
patient  let  alone. 

Dr.  Janeway  practices  aspiration  once  or  twice. 
If  he  finds  that  the  sac  diminishes  after  each  aspira- 
tion, he  considers  the  case  doing  well,  and  continues 
the  treatment ;  in  some  cases  repeating  the  opera- 
tion several  times.  When,  however,  such  success 
does  not  attend  this  procedure,  he  makes  2,perina~ 
ne7it  opening  in  the  chest  wall,  inserting  a  drainage 
tube  and  washing  out  the  cavity  with  a  dilute  solu- 
tion of  carbolic  acid. 

Dr.  W.  M.  Polk  keeps  up  the  patient's  strength 
by  the  administration  of  iron,  quinine,  and  sometimes 
strychnine,  combined  with  a  most  nutritious  diet  and 
occasional  moderate  stimulation. 


54  PLEURISY. 

The  following  is  used  at  this  hospital; 

]^.     SoL  quiniai  sulph.    (gr.  xv.-3i.)    .      §  il 
Tinct.  ferri  chlor.  .         .         .     3ii 

M.     Dose  :  A  teaspoonful. 

Aspiration  is  first  employed,  but  sometimes,  after 
this  has  been  practiced  repeatedly,  the  pus  re-accu- 
mulates, and  the  patient  becomes  anaemic,  weak,  and 
loses  health.  In  such  cases  he  performs  operation 
with  the  best  results.  This  has  been  followed  by  re- 
covery in  many  instances  where,  to  all  appearances, 
the  patient  was  fast  failing  under  repeated  aspira- 
tion. 

Indeed,  it  may  be  said  that  a  permanent  opening 
is  the  rule  at  this  hospital.  In  cases  of  simple  em- 
pyema, where,  after  aspiration,  the  fluid  increases 
and  the  patient  shows  emaciation  with  hectic,  this 
procedure  is  very  generally  practiced.  A  free  in- 
cision is  made,  and  the  pus  evacuated,  giving  almost 
instant  relief  to  the  dyspnoea,  and  followed  by  im- 
provement. A  drainage  tube  is  usually  employed, 
and  the  cavity  washed  out  daily  with  carbolized 
water,  1-200  or  i-ioo;  or  some  cases  often  do  well 
by  simply  keeping  the  opening  closed  with  a  tent. 

NEW  YORK  HOSPITAL. 

Acute  Pleurisy. — Dr.  W.  H.  Draper  directs 
that  the  patient  be  put  to  bed  and  rest  and  quiet 
obtained.  Good  nutrition  is  secured  and  stimulants 
given  when  indicated.  If  there  is  much  weakness 
and    prostration    present,  aDinioniuin  earbojiate   and 


PLEURISY.  55 

Spirit  of  mindereriis  are  administered.     The  follow- 
ing solutions  are  very  much  used  at  this  hospital : 

Concentrated. 
!p.    Acid,  acetic.  .         .  .         .       §  ii. 

Aquae  fervent.       .         .  .         .       3  ii. 

Ammonii  carbon.  .  .         .      q.  s. 

Ft.  sol.  neutral.  Evaporate  to  5  ii. 
This  keeps  well. 

Dilute. 
9.     Liq.  ammon.  acet.  cone.      .         .  31. 

Aquae  acidi  carbonici  .         .       J  xv. 

M. 

Counter-irritation  by  means  of  iodine,  is  applied 
to  the  chest,  combined  with  some  diuresis.  Blisters 
are  also  employed  ;  the  application  of  a  sharp  blister, 
two  or  three  inches  square,  being  often  followed  by 
the  most  excellent  results. 

Subacute  Pleurisy. — In -many  instances.  Dr. 
Draper  considers  this  as  practically  a  dropsy  of 
the  chest  and  treats  accordingly.  The  patient  is 
provided  with  a  most  nutritious  diet,  and  absolute 
rest  enforced.  Counter-irritation  by  means  of  iodine 
is  applied  to  the  chest,  combined  with  the  adminis- 
tration of  diuretics.  Of  these  he  sometimes  uses 
digitalis,  or  digitalis  and  iodide  of  potassium. 

The  following  diuretic  pill  is  often  used  at  this 
hospital : 

^.    Pulv.  scillae 
Pulv.  digitalis 

Massa  hydrarg.         .  .  .       aa  gr.i. 

M.    Ft.  pil.  No.  i. 


56  PLEURISY. 

Or,  in  many  cases,  the  so-called  ^^ diuretic  wine''' 
(squill,  digitalis,  and  potassium  acetate)  is  employed. 

If,  however,  from  a  continued  use  of  this  prepara- 
tion the  effects  of  digitalis  on  the  pneumogastric 
nerve  become  marked,  its  administration  is  stopped 
and  the  salines  given. 

The  following  is  from  this  hospital : 

^.    Potass,  acetat.            .  .  .  3  ii. 

Potass,  et  sodii  tart.  .  .  §  i. 

Syrup,  zingiber.         .  .  .  §  i. 

Aquae      .         .           .  •  •  5  iii- 
M. 

After  one  or  two  weeks,  should  these  measures  fail 
to  make  any  impression  on  the  effusion,  puncture  is 
resorted  to  and  the  fluid  withdrawn  by  the  aspirator. 
This,  Dr.  Draper  considers  the  only  reliable  means, 
particularly  where  the  effusion  is  in  large  amount. 
The  needle  is  sometimes  introduced  in  the  fifth  or 
sixth  intercostal  space,  along  the  axillary  line ;  but 
usually  the  eighth  or  ninth  space  posteriorly  is  se- 
lected, on  a  line  let  fall  from  the  inferior  angle  of  the 
scapula. 

Empyema. — Dr.  J.  W.  McLane  in  many  cases 
favors  the  operative  treatincjit ;  a  drainage  tube  is 
inserted  and  full  Lister  dressing  employed.  For 
washing  out  the  cavity,  he  sometimes  uses  a  warmed 
solution  of  thymol,  i-iooo.  He  directs  that  careful 
attention  be  given  to  the  rigid  exclusion  of  all  air 
from  the  pleural  sac,  until  the  crippled  lung  has  had 
ample  time  to  expand  and  contract  adhesions  ;    and 


PLEURISY.  57 

even  then  none  should  be  admitted  that  is  not  ren- 
dered thoroughly  antiseptic.  He  also  insures  a  grad- 
ual withdrawal  of  the  pus  and  a  free  exit  of  the  fluid 
while  washing  out  the  cavity,  in  order  that  fresh 
adhesions  between  the  two  pleural  surfaces  may  not 
be  broken  up.  By  these  means  most  gratifying 
results  obtain. 

Dr.  Draper,  in  certain  cases,  employs  the  aspira- 
tor very  effectually,  supporting  the  patient  with  good 
nutrition,  etc.  In  other  instances  where  the  general 
condition  is  bad,  with  hectic  and  night-sweats,  a  per- 
manent opening  is  made  and  free  drainage  estab- 
lished. 

For  a  tonic,  the  following  is  often  employed  at  this 
hospital  with  excellent  effect : 

5.    Tinct.  ferri  chlor.     .  .  .  J  vi. 

Strychniae  sulph.       .  .  .  grs.  viii. 

Cinchonid.  sulph       .  .  .  •     5  i- 

Tinct.  zingib.            .  .  .  .    3  ii. 

Glyce  rinse 

Acid,  phosphor,  dil.  .  .  aa.  §  xvi. 

M.     Dose:  A  teaspoonful  three  times  daily. 

Fibrous  Pleurisy. — In  extreme  cases  where  the 
functions  of  the  lungs  are  greatly  diminished,  caus- 
ing interference  with  the  pulmonary  circulation,  with 
possibly  commencing  oedema.  Dr.  Draper  enjoins 
complete  rest  in  the  recumbent  position  and  avoid- 
ance of  all  excitement.  If  signs  of  approaching  col- 
lapse are  apprehended,  alcohol  and  digitalis  are  given 
and  dry  cupping  applied.     After  relieving  the  imme- 


58  PLEURISY. 

diate  symptoms,  counter-irritation  by  iodine  is  then 
resorted  to  and  kept  up  for  some  time.  The  follow- 
ing is  the  formula  for  the  tincture  used  at  this  hos- 
pital : 

]^.    lodinii         .         .         .         .         .  3  i- 

Potassii  iodidi     .         .         .         .  3  ii* 

Aquae  destil. 
Alcohol.  .         .         .         .    aa.  5  ii. 

M. 

For  the  dyspnoea,  opium  with  digitalis  is  given  af- 
fording much  relief.  Quebracho  is  also  frequently 
used  for  this  purpose,  either  alone  or  with  opium,  and 
the  dyspncEa  often  greatly  alleviated ;  but  this 
remedy  is  at  times  variable  in  its  result.  This  con- 
dition frequently  arising  from  poor  nutrition.  Dr. 
Draper  advises  especial  care  in  regard  to  the  food. 
Diuretics  and  diaphoretics  are  rarely  resorted  to. 
He  finds  that  these  patients  improve  in  a  marked  de- 
gree upon  a  regular  systematic  diet,  which  at  the 
same  time  must  be  of  the  most  nutritious  quality. 
With  this  he  also  administers  cod  liver  oil  and  iron, 
the  good  effects  of  which  are  especially  prominent  in 
children.  The  following  emulsion  is  used  at  this 
hospital : 

^.    Ol.  morrhuae  .         .         .  3  vi. 

01.   anisi  .         .         .         .  3  ss. 

01.  sassafras    .  ...     gtt.  x. 

Liq.  calc.  sacchar.      .         .         .  '^li, 

M. 

(Not  compatible  with  acids). 


PLEURISY.  59 

He  does  not,  however,  expect  much  from  these 
cases,  although  the  patient  may  be  relieved  of  a  great 
part  of  the  distress,  and  the  fluid  exudation  dimin- 
ished ;  and  with  especial  care  regarding  nutrition, 
etc.,  considerable  benefit  sometimes  follows. 

ROOSEVELT    HOSPITAL. 

Acute  Pleurisy. — To  diminish  the  severity  of 
the  inflammation,  Dr.  Francis  Delafield  employs 
blood-letting  or  counter-irritation.  When  the  patient 
is  young  and  robust  and  the  pain  very  severe,  he  ap- 
plies wet  cups  immediately  to  the  affected  side.  In 
asthenic  or  elderly  persons,  or  where  the  pain  is  of  a 
milder  character,  dry  cups  or  blisters  usually  suffice. 
In  all  cases,  however,  he  directs  that  the  counter- 
irritation  be  rapid  and  decided.  For  the  pain,  if  nec- 
essary, he  gives  opium  in  moderate  dosage,  either  by 
the  mouth  or  hypodermically.  In  sthenic  patients 
with  much  fever,  he  also  administers  aconite  in  small 
doses  and  spirit  of  niindererus.  After  the  acute 
symptoms  have  subsided,  counter-irritation  is  con- 
tinued by  means  of  blisters,  and  diuretics  given  inter- 
nally ;  at  the  same  time  supporting  the  strength  of 
the  patient  with  tonics  and  good,  nutritive  food.  In 
acute  pleurisy  occurring  with  Bright's  disease  where 
there  is  more  or  less  oedema  of  the  face,  etc.,  he  ap- 
plies a  blister  to  the  chest,  and  orders  : 

]^.     Potass,  iodid.        .         .         .         grs.  x. 
Syrup,  ferri  iodid.         .         .      m.  xxx. 
M.     Sig.  Dose,  three  times  daily. 


60  PLEURISY. 

This  is  often  followed  by  the  most  favorable  re- 
sults. 

Subacute  Pleurisy. — In  very  mild  cases  where 
the  effusion  is  slight,  Dr.  Delafield  advises  that 
the  patient  stop  work  altogether,  if  possible,  and 
take  plenty  of  good  food  and  rest.  With  this  he 
combines  the  occasional  application  of  small  blisters 
over  the  site  of  the  pleurisy.  As  a  rule,  however, 
his  treatment  is  directed  to  getting  rid  of  the  fluid, 
and  supporting  the  patient  with  tonics  and  nourish- 
ing diet.  For  the  effusion  he  resorts  to  persistent 
counter-irritation  by  means  of  blisters,  combined 
with  the  administration  of  diuretics.  One  blister 
is  applied  at  a  time,  each  succeeding  one  to  be  placed 
in  position  as  the  former  heals.  For  diuresis  he  gives 
digitalis  and  the  iodide  and  acetate  of  potassium.  If 
after  some  time  no  success  attends  this  method,  it  is 
discontinued  and  tonics  tried  for  a  while  ;  then  again 
alternating  with  counter-irritation  and  diuresis.  For 
a  tonic,  the  following  is  often  made  use  of  at  this 
hospital : 

^.    Tinct.  ferri  chlor.  .         .         §  xii. 

Strych.  sulph.         .         .         .     grs.  xvi. 

Syrup,  simp. 

Aquae  .         .         .         .      aa  Oiv. 

M.    Dose  :     Two  teaspoonfuls. 

Dr.  Delafield's  indications  for  immediate  aspir- 
ation are,  {a)  when  the  fluid  accumulates  so  rapidly 
as  to  threaten  danger  from  dyspnoea,  and  {U)  when 
the  fluid  remains  unabsorbed  and  the  patient  steadily 


PLEURISY.  6l 

deteriorates  in  health.  If  the  effusion  does  not  dis- 
appear and  yet  the  patient  continues  in  a  fair  con- 
dition, he  advises  the  above  treatment  even  for 
months,  before  resorting  to  tapping. 

Empyema. — In  children,  Dr.Delafield  considers 
aspiration  best,  repeated  as  often  as  indicated.  In 
doing  this  he  prefers  to  use  the  trocar  and  canula 
instead  of  the  usual  aspirating  needle.  In  adults, 
however,  he  more  frequently  makes  2.  free  incision  in 
the  chest  wall,  selecting,  as  a  rule,  the  sixth  intercos- 
tal spa.ce  in  the  axillary  line  posteriorly,  introducing 
a  drainage  tube  and  establishing  a  permanent  open- 
ing. If  the  pus  is  small  in  amount  or  sacculated, 
then  the  aspirator  may  be  used.  Washing  out  the 
pleural  cavity  with  either  water,  carbolic  acid  solu- 
tion, or  a  weak  solution  of  zinc  chloride,  he  considers 
a  somewhat  dangerous  procedure,  although  it  is  not 
infrequently  resorted  to.  For  constitutional  treat- 
ment, he  administers  tonics,  cod  liver  oil,  nutritious 
food,  etc.,  and  advises  a  change  to  a  warmer  climate. 
The  following  excellent  preparation  of  cod  liver  oil 
is  used  at  this  hospital  : 

5.    01.  morrhuae     ....  3  ii. 

Spts.  lavandulce  co. 

Vini  gallici        .         .         .         .       aa  3  i. 
M.     Sig.  Dose. 

When,  however,  the  aspirator  has  been  employed 
and  the  patient  shows  poor  nourishment,  with  fever, 
exacerbations,  and  night-sweats,  which  tonics,  quinine, 
etc.,   fail  to   improve,   both    Drs.    Delafield   and 


62  PLEURISY. 

Draper  advise  that  a  free  opening  be  made,  the  pus 
evacuated,  a  drainage  tube  introduced  and  the  chest 
cavity  washed  out  with  a  warm  sokition  ;  for  this 
purpose  sometimes  using  a  solution  of  boracic  acid, 
grs.  v-3  i.,  or  a  warmed  carboHc  acid  solution.  The 
full  Lister  dressing  is  usually  employed  in  the  opera- 
tion. 

Fibrous  Pleurisy. — Dr.  Delafield  applies 
persistent  counter -irritation  over  the  affected  side 
with  iodine  for  many  months.  This  he  also  com- 
bines with  the  administration  of  those  agents  which 
improve  the  strength  and  nutrition,  such  as  iron,  eod 
liver  oil,  or  cream,  etc.,  and  advises  the  patient  to 
seek  a  warm  climate  during  the  winter  months.  The 
formula  for  the  iodine  tincture  employed  at  this 
hospital  is  as  follows : 

5.    lodinii        .....§  iiss. 
Potass,  iodidi     .... 
Alcoholis    ..... 
Aquae  ..... 


1 

ss. 

3  • 

xii 

I 

iv, 

M. 


PRESBYTERIAN  HOSPITAL. 


Acute  Pleurisy. — When  there  is  a  condition  of 
high  temperature,  with  an  excruciating  pain  which  is 
only  partially  allayed  by  opium,  it  is  found  that  one 
or  two  leecJies  applied  over  the  affected  side  relieves 
the  pain  almost  instantly  and  for  a  long  time. 

Subacute  Pleurisy.— ^As  a  rule,  Dr.  Hadden 
first  places   the  patient  on   tonic  and  diuretic  treat- 


PLEURISY.  63 

ment.  This  is  continued  for  a  time,  after  which,  if 
the  fluid  is  not  reduced  by  this  means,  aspiration  is 
resorted  to. 

Empyema. — When  the  effusion  becomes  purulent, 
Dr.  Hadden  favors  the  estabHshing  of  2,  permanent 
opening  with  'drainage,  and  washing  out  the  cavity 
daily. 

ST.  FRANCIS'  HOSPITAL. 

Acute  Pleurisy. — At  the  onset  of  the  attack, 
with  high  temperature,  rapid  pulse  and  respiration, 
and  severe  pain,  Dr.  J.  H.  RiPLEY  gives  the  follow- 
ing with  great  advantage  : 

]^.    Tinct.  aconiti  rad.         .         .         .  gtt.  xx. 

Tinct.  opii  camph. 

Spts.  aetheris  nitrosi    .         .  .   aa  5  ss. 

Liq.  ammon.  acet.      .  .  .  5  v. 

M.     Sig.     A  tablespoonful  every  three  hours. 

Where  considerable  prostration  is  present,  and  the 
temperature  continues  high,  quinine  is  given  in  large 
doses  and  stimulants  administered  freely.  When,  in 
these  cases,  the  effusion  is  abundant,  and  dyspnoea 
marked,  he  uses  the  following : 

1^.    Tinct.  digitalis        .         .         .         .31. 

Potass,  acetat.         .         .  .         .      3  ii. 

Aquae  ad.        .  .  .  .  .     3  iv. 

M.     Sig.     A  tablespoonful  every  three  hours. 
Should,  however,   the    dyspnoea   become    intense 
from  the  excessive  increase  of  fluid,  and  other  means 
fail  to  relieve.  Dr.  Ripley  resorts  to  aspiration  at 


64  PLEURISY. 

once,  and  often  with  excellent  effect  on  the  exuda- 
tion. 

Empyema. — Dr.  Ripley  is  in  favor  of  making  a 
free  incision  in  the  chest  wall,  evacuating  the  pus, 
and  inserting  a  drainage  tube. 

ST.  LUKE'S  HOSPITAL. 

Acute  Pleurisy. — Dr.  C.  W.  Packard  advises 
early  removal  of  the  sero-fibrinous  exudation,  so  that 
the  lung  may  re-expand  at  once  on  withdrawal  of  the 
fluid.  For  if  time  has  been  given  for  the  formation 
of  tough  and  strong  membranes,  the  lung  may  be 
tied  up  by  adhesions  so  that  it  cannot  get  free  for  a 
long  time — sometimes  not  at  all,  and  is  thus  left  in 
a  favorable  condition  to  take  on  disease  and  run  into 
fatal  phthisis.  A  latent  pleuritic  effusion,  the  result 
of  a  low  grade  of  inflammatory  action,  and  contain- 
ing very  little  fibrin,  he  believes  may  be  safely  left 
for  many  weeks.  But  in  acute  pleurisy,  when  the 
ordinary  remedies  have  failed  to  bring  about  absorp- 
tion, he  thinks  that  three  weeks  is  the  outside  limit 
of  safety ;  and,  in  such  cases,  by  drawing  off  even  a 
part  of  the  fluid  he  allows  the  lungs  to  expand  and 
break  the  still  tender  bands  of  exudation  present. 

Empyema. — Dr.  Packard  considers  the  demand 
for  early  operation  imperative.  When,  after  aspira- 
tion, the  pus  is  decreasing  and  the  constitutional  dis- 
turbance is  moderate,  and  especially  in  young  sub- 
jects, he  would  hope  for  ultimate  cure  by  aspiration. 
But  if  the  pain  and  irritation  continue  severe  and  the 
pus  rapidly  re-accumulates,  he  advises  that  the  plcu- 


PLEURISY.  65 

ral  sac  be  opened  by  an  incision  large  enough  to 
admit  of  a  ready  evacuation  of  its  contents  and  the 
washing  out  of  its  cavity. 

In  regard  to  the  surgical  treatment  of  this  disease 
Dr.  a.  C.  Post  believes  in  the  superiority  of  the 
radical  operation.  He  thinks  it  highly  desirable  to 
make  -^x  free  incision,  as  the  fluid  is  often  so  viscid 
that  it  will  not  flow  through  the  needle  of  the  aspi- 
rator. By  this  practice  he  has  frequently  obtained 
marked  results  in  cases  where  relief  had  not  followed 
aspiration.     This  he  finds  especially  true  of  children. 

CHARITY  HOSPITAL. 

Acute  Pleurisy. — In  children,  at  the  commence- 
ment, Dr.  J.  Lewis  Smith  directs  his  treatment 
toward  reducing  the  inflammation  and  limiting  the 
exudation.  For  the  former  indication  he  directs  that 
blood  be  abstracted  by  the  application  of  leecJies, 
two  in  a  child  under  two  years,  or  three  in  an  older 
one.  He  insists,  however,  that  this  be  done  only  at 
the  commencement  of  acute  primary  pleurisy  in 
robust  children,  and  then  only  leeches  should  be 
used.  He  also  employs  other,  and  what  he  frequently 
considers  better,  means  for  this  purpose,  namely,  a 
mild  rubefacient  composed  of : 

Mustard  .         .         .  .         one  part. 

Linseed  .  .  .  sixteen  parts. 

This  is  covered  with  oil-silk   and  applied  twice  daily. 
He  objects  to  the  use  of  blisters  at  this  early  stage, 
as  he  finds  that  it  increases  the  area  of  imflamma- 
5 


66  PLEURISY. 

tion.  The  application  of  cold  is  also  objected  to. 
Dr.  Smith  further  resorts  to  the  cardiac  sedatives, 
aconite  or  veratrum  viride,  according  to  the  age  of 
the  child ;  but  advises  that  they  be  administered 
with  care  and  their  effects  closely  watched.  For 
infants  he  prefers  quinine  and  digitalis.  Opiates  are 
also  used  for  the  pain  and  cough,  on  some  occasions 
giving /?//?7.  Doveri^  grs.  i-iii.  every  tJiree  Jioiirs.  He 
frequently  prescribes  the  following  with  very  excel- 
lent service  in  these  cases: 

5.    Tinct.  ipecac,  co.       .         .         .     gtt.  xvi. 
Tinct.  aconiti  .         .         .     gtt.  viii. 

Syr.   tolutan.  .  .         .  5  "• 

M.   Sig.   Half  a  teaspoonful  every  two  hours. 

Subacute  Pleurisy. — For  the  removal  of  the 
fluid  Dr.  Smith  first  employs  other  measures  before 
proceeding  to  aspiration.  In  adults  he  finds  the 
hydragogue  cathartics  very  useful ;  but  in  children 
he  considers  them  too  depressing,  and  obtains  more 
satisfactory  results  from  diuretics.     He  gives: 

^.     Potass,  acetat.      .         .         .         .        3  ss. 
Infus.  digitalis      .  .  .  .        ^  ii. 

M.  Sig.  A  teaspoonful  every  six  hours. 
The  diet  is  made  full  and  nutritious,  with  but  little 
fluid.  His  treatment,  however,  varies  with  the  indi- 
cations of  each  special  case.  When  the  appetite 
and  general  health  are  good,  and  no  symptoms  due  to 
the  presence  of  fluid  are  manifest,  but  little  is  done 
in  the  way  of  medication.  When  such  symptoms 
are  prominent,  and  there   is  no   evidence  of  dimin- 


PLEURISY.  6j 

ishing  fluid,  thoracentesis  is  resorted  to.  His  indica- 
tions for  performing  this  operation  are  as  follows  : 
(a)  where  the  effusion  completely  fills  one  pleural  cav- 
ity, compressing  the  opposite  lung  ;  (b)  in  double 
pleurisy  whe-n  the  sacs  are  half  filled ;  (c)  where 
severe  attacks  of  orthopnoea  are  present ;  and 
(d)  when  the  pleural  cavity  is  half  filled  with  fluid, 
which  has  existed  for  one  month.  For  the  opera- 
tion Dr.  Smith  prefers  to  use  the  aspirator  with 
a  trocar  and  canula  attached,  instead  of  the  usual 
aspirating  needle  ;  thus  avoiding  the  danger  of  injur- 
ing the  lung,  which  not  infrequently  occurs  where 
the  needle  is  used,  either  from  the  suction  force 
employed  or  by  occasional  moving  of  the  point  of 
the  needle  to  liberate  it  from  particles  of  fibrinous 
material.  Where  the  fluid  is  sero-fibrinous  he  uses 
the  small  trocar  and  allows  the  opening  to  close,  one 
tapping  being  usually  sufficient. 

Dr.  Beverly  Robinson  performs  thoracentesis 
(a)  in  all  cases  where  there  is  imminent  danger  to 
life  from  presence  of^  the  effusion;  (b)  in  all  cases 
without  delay  when  the  fluid  is  abundant ;  and  (c) 
in  cases  of  moderately  or  appreciably  large  effusion. 
In  these  latter  instances  he  claims  that  if  the  use  of 
the  aspirator  is  supported  by  purgatives  and  diuret- 
ics in  robust  patients,  and  more  particularly  by  tonics- 
and  moderate  stimulation  in  those  who  are  weakened 
and  losing  appetite  and  flesh,  that  the  re-accumula- 
tion of  the  fluid,  if  drawn  off  during  the  formative 
or  ascending  period,  is  neither  necessary  nor  proba- 
ble ;    nor    does   thoracentesis    practiced    during   the 


68  PLEURISY. 

febrile  period,  have  any  injurious  effect  upon  the 
ultimate  course  of  the  effusion.  By  withdrawing  a 
portion  of  the  fluid,  also,  the  absorbents  are  relieved 
from  pressure,  and  can  more  readily  perform  their 
function. 

Empyema. — When  the  effusion  has  become  puru- 
lent, Dr.  Smith  proceeds  to  evacuate  it.  For  this 
purpose  he  employs  the  large  trocar,  passing  it  to 
the  depth  of  about  five-eighths  of  an  inch.  The 
canula  is  then  attached  to  the  reversible  aspirator^ 
the  fluid  withdrawn,  and  the  cavity  washed  out  with 
a  carbolic  acid  solution  of  about  i-ioo.  A  fistulous 
opening  is  then  established  by  introducing  two 
threads,  double,  and  permitting  them  to  remain.  If 
the  pus  is  fetid  the  washing  out  is  repeated  every 
one  or  two  days,  otherwise  not.  By  this  means  he 
usually  finds  improvement  attending  each  aspiration. 
Where,  however,  after  each  tapping,  soon  as  the  pus 
re-collects  the  patient  become§  worse,  he  resorts  to 
/rrr  ^/^;//;2^  with  drainage.  In  all  cases.  Dr.  Smith 
urgently  advises  great  care  in  aspirating.  He  would 
never  allow  the  point  of  the  aspirator-needle  to 
remain  in  the  chest  while  suction  was  being  made. 

MT.  SINAI   HOSPITAL. 

Subacute  Pleurisy. — In  children  where  there  is 
much  fever.  Dr.  jACOBlgives^?/^/;?/^  sulpJi.,  grs.  viii. 
daily  until  the  temperature  is  reduced.  To  lessen 
the  amount  of  fluid,  in  some  instances  he  applies 
co2mtcr-ir)'itation  by  means  of  blisters,  iodine,  etc. 
This,  however,  is  quite  annoying  and  where  the  child 


PLEURISY.  69 

is  feeble  it  needs  all  the  sleep  possible.  In  such 
cases  he  uses  diuretics,  giving  potassium  bitartrate, 
3  i—tss.  daily,  and, 

5.    Potass,  iodid.     .         .  .  grs.  v. 

Aquae  q.  s. 

M.   Sig.   Dose,  four  times  daily. 

With  these  he  employs  diaphoresis  by  means  of 
the  cold  pack,  or,  where  the  feet  do  not  re-act,  heat  is 
also  applied  to  those  parts.  In  weak  and  enfeebled 
children  he  considers  the  hot-water  pack  better, 
combined  with  which  he  administers  liquor  amnion, 
acetat.,  z^^-  i^  3-  cupful  of  hot  milk. 

Dr.  Jacobi  also  us&sjaboraTtdi,  at  times,  preferring 
pilocarpine,  however,  as  its  effects  of  nausea  and 
salivation  are  less  marked.  This  he  gives  hypoder- 
mically,  as  follows  : 

5.      Sol.  pilocarpine  (2  per  cent.)     .      m.  xv. 

Sig.      Dose,  for  children. (m.  xxx.  to  adults). 

Profuse  sweating  usually  follows  immediately, 
continuing  from  half-an-hour  to  one  hour,  which  he 
finds  of  great  service. 

Empyema. — When  suppuration  takes  place,  Dr. 
Jacobi  immediately  resorts  to  evacuation,  some- 
times employing  the  aspirator,  or  in  many  instances 
making  a  free  opening  with  drainage. 

Surgery  axd  Antisepsis. — In  regard  to  the 
surgical  and  antiseptic  measures  to  be  adopted,  the 
following  will  ver\^  generally  apply :  In  case  the 
intercostal  space  is  very  narrow,  a  section  of  the  rib 
at  or  near  the  most  dependent   portion  of  the  cavity 


70  PLEURISY. 

may  be  removed.     After  evacuation  of  the  pus,  the 
pleural   cavity   should   then   be   washed   out   with  a 
weak  solution  of  carbolic  acid,   and   a  drainage  tube 
introduced,  transfixed  with  a  wire  or  long  needle  to 
prevent  its  slipping  into  the  thorax.     A  thick  Lister 
dressing  is  now  to  be  applied  which  will  absorb  the 
escaping  pus.     For  the  first  ten  days  the  dressing  is 
to  be  renewed   daily.      It   is   also   essential   that  the 
patient  be  cautioned  to  assume  frequently  a  position 
which  will  facilitate  exit  of  the  discharge.     The  incis- 
ion may  be  made  preferably  at   the  angle  of  the  rib 
posteriorly.     If  incision   through   a  single   space  be 
not  sufficient,  a  double  incision  should  be  made  or  a 
section  of  the   rib   removed.      If  the  discharge  does 
not  become  offensive   after  the   first  washing-out,  it 
need  not  be  repeated.     The   drainage  tube   may  be 
changed  for  one  of  smaller  size  as  the  case  progresses, 
and  should  be  removed  and  cleaned  at  each  dressing, 
since  it  may  become  occluded  by  pus  or  granulations. 
As  the  pus  diminishes  the  tube  may  be  replaced  by 
a  tent  of  gauze  and  this  finally  removed.     It  is  to  be 
discontinued,  however,  only  when  the  discharge  has 
finally  ceased. 


HYDROTHORAX— HYDROPNEU- 
MOTHORAX. 


Definition. — A  simple,  non-inflammatory  effusion 
into  the  pleural  cavities,  occurring  in  the  course  of 
wasting  diseases,  with  Bright 's  disease  and  general 
anasarca.  Hydropneumothorax. — An  effusion  of  fluid 
with  gas  or  air  in  the  pleural  cavity. 

NEW  YORK  HOSPITAL. 

HYDROTHORAX. — If  the  effusion  be  slight,  Dr. 
W.  H.  Draper  administers  diuretics,  diaphoretics 
and  cathartics ;  but  he  finds  that  these  fail  in  the 
majority  of  cases,  more  particularly  if  the  fluid  is  in 
large  amount.  Aspiration  he  considers  the  only 
reliable  means  of  relief ;  this  is  prompt,  efficient  and 
should  not  be  postponed,  especially  where  dyspnoea 
is  severe.  He  advises  that  it  is  never  safe,  however, 
to  abstract  all  of  the  fluid  at  once,  as  its  sudden 
removal  may  cause  fatal  syncope.  His  plan  is  to 
tap  in  the  erect  position,  allowing  the  flow  to  con- 
tinue until  the  breathing  is  relieved  ;  the  operation  to 
be  repeated  soon  as  the  dyspnoea  again  appears. 
Saline  cathartics  and  diuretics  also  afford  much 
benefit.  Frequently  by  this  means  and  attention  to 
the  diet,  which  should  consist  largely  of  albuminous 

71 


72   HYDROTHORAX — HYDROPNEUMOTHORAX. 

foods    and    diluent    drinks,   the    patient    is    greatly 
improved. 

HYDROPNEUMOTHORAX. — In  caseswhere  a  circum- 
scribed empyema  suddenly  opens.spontaneously  into 
a  bronchial  tube,  and  prostration  becomes  extreme, 
Dr.  Draper  advises  that  immediate  and  vigorous 
stimulation  is  demanded.     He  gives  : 

^.     Spts.  vini  gall.       .         .         .         .  5  i- 

Infus.  digitalis       .         .         .  .  3  L 

Ammon.  carb.       ....    grs.  v. 

Sig.     Dose,  every  hour. 

BELLEVUE    HOSPITAL. 

Hydrothorax. — Simple  hydrothorax  is  treated 
by  Dr.  Loomis  as  an  ordinary  dropsy,  with  diapho- 
re'tics,  diuretics  and  hydragogues.  In  severe  cases 
where  i«nstant  relief  is  demanded,  the  aspirator  is 
resorted  to. 

Dr.  Alonzo  Clark  administers  saline  diuretics 
and  digitalis.  His  favorite  among  the  diuretics  is 
potassium  carbonate,  which  he  prescribes  thus: 

5-    Potass,  carbon.        .         .         .         grs.  xx. 

Aquae     .....  3  ss. 

M.    et  add 

Succi  limonis  recent        .         .  5  ss. 

Sig.     Dose,  every  two  hours. 

With  this  he  also  gives, 

IJ.     Infus.  digitalis         .         .         .  3  i-ii. 

Sig.     Dose,  three  times  daily. 

In  many  instances  he  advises  the  stearn-bath,  taken 


HYDROTHORAX — HYDROPNEUMOTHORAX.         73 

at  night,  with  much  benefit,  combined  with  friction 
over  the  entire  body  in  the  morning. 

HYDROPNEUMOTHORAX. — If  seen  at  the  moment 
of  attack.  Dr.  Loomis  gives  morphia  hypodermicaliy 
two  or  three  times  daily.  After  which,  and  the 
imediate  effect  of  .the  perforation  is  recovered  from, 
the  system  is  supported  by  st-imu-lants  and  good 
food.  In  extreme  cases,  where  the  fluid  is  excessive 
in  amount,  and  accompanied  by  high  fever  with 
severe  dyspnoea,  a  free  opening  is  made,  although  he 
considers  this  procedure  only  palliative. 

Dr.  Alonzo  Clark  aims  to  prolong  life  to  the 
utmost  by  the  administration  of  good  food  and  stim- 
ulants. He  also  employs  some  counter  irritant, 
applied  to  the  chest,  such  as  zinc  iodide.  A  perma- 
nent opening  is  also  made  to  allow  escape  of  the 
pus. 

Dr.  Francis  Delafield  advises  that  a  free 
incision  be  made  and  a  permanent  opening  estab- 
lished. Should  symptoms  of  collapse  be  prominent, 
he  cautions  that  the  administration  of  stimulants  be 
not  delayed.  Alcohol  should  be  given  in  full  doses  to 
bring  the  radial  pulse  full  and  strong. 


PULMONARY  PHTHISIS. 


Definition. — Lesions  commencing  with  indura- 
tion of  a  lobe  or  lobule  of  the  lungs,  ending  in  disin- 
tegration of  the  new  material  and  of  the  textures 
involved  in  the  induration  ;  the  formation  of  caverns, 
and  the  accumulation  and  constant  discharge  of  pur- 
ulent secretion,  with  or  without  the  growth  of  mil- 
iary tubercles  (Aitken). 

BELLEVUE  HOSPITAL. 

Dr.  Loomis  places  the  patient  on  a  simple,  yet 
highly  nutritious  diet,  administered  frequently  and 
to  the  full  of  digestion.  Milk  is  considered  best,  or 
milk  with  yolk  of  eggs,  especially  in  the  later  stages. 
For  internal  medication,  his  means  are  of  course 
varied.  To  control  the  fever,  he  prefers  quinine  as 
the  most  reliable,  and  also  believes  that  no  other  drug 
exerts  so  great  influence  over  the  early  stage  of  catar- 
rhal phthisis.      He  usually  gives : 

IJ.     Quiniae  sulph.   ....    grs.  xx. 

Sig.   To  be  taken  daily,  in  one  or  two  doses. 

This  amount  is  increased  or  diminished  according 
to  indications.  Unless  the  fever  subsides,  however, 
he  continues  it  up  to  the  verge  of  cinchonism.  Inhal- 
ations are  objected  to,  except  in  the  catarrhs  of  the 

74 


PULMONARY   PHTHISIS  75* 

early  stage  when  they  are  sometimes  attended  with 
marked  improvement.  For  the  vomiting  various 
remedies  are  at  times  employed.  Champagne  taken 
with  the  food  is  often  very  serviceable  ;  also  hydro- 
cyanic acid,  pepsin,  etc.  Dr.  Loomis,  however, 
places  most  reliance  upon  the  following :  he  directs 
the  patient  to  take,  every  half-hour,  from  half  to  a 
teaspoonful  of  raw  scraped  beef,  made  into  a  sand- 
wich ;  this  is  to  be  continued  for  forty-eight  hours, 
during  which  the  patient  must  be  kept  quiet  and  in 
the  recumbent  position.  In  regard  to  cod  liver  oil, 
he  advises  that  it  be  combined  with  an  alkali,  avoid- 
ing stimulants  if  possible.  For  administration,  he 
generally  begins  with  olei  niorrhucs^  3  i-  once  or 
twice  daily  after  meals.  This  is  afterward  increased 
to  3  ss.  three  times  daily.  The  following  emulsion 
is  very  often  used  at  this  hospital  : 

5-    Olei  morrhuae         .  .         .         .      5  ii- 

Aquae  calcis  .        .  .  .         .      3  ss. 

Syr.  calcis  lactophosph.  .         .     5  iss. 

M. 

In  fibrous  phthisis,  cod  liver  oil  may  be  taken  if  it 
agrees  with  the  patient,  but  he  finds,  as  a  rule,  that 
it  does  not  benefit  this  class  of  cases.  In  his  expe- 
rience greater  reliance  is  to  be  placed  on  arsenic, 
iron,  and  strychnia.  These  he  believes  to  be  most 
serviceable  of  any,  particularly  a  combination  of 
arsenic  with  iron.  The  following  is  from  this  hos- 
pital : 

5-    Quiniae  sulph.        .         .         .         .        3  i-        ■ 
Fgrri  redact]  .  ...      3  iss. 


"J^  PULMONARY   PHTHISIS. 

Acid,  arseniosi 

Strychnise     .         .         .         .       aa  grs.  iii. 
Confect.  rosae       .  .  .  .       q.  s. 

M.    ft.  pil.  No.  Ix. 

Alcohol  he  considers  of  service  only  when  it  in- 
creases the  appetite  and  digestion  of  the  patient,  and 
stimulates  the  physical  powers.  In  the  earlier  stages, 
however,  he  does  not  advise  the  use  of  stimulants. 
Where  anaemia  is  present,  with  no  fever,  a  course  of 
iron  is  administered  with  much  benefit.  The  night- 
sweats  are  often  controlled  by  quinine  in  large  doses. 
When  this  fails,  Dr.  LOOMIS  prescribes  digitalis, 
opium,  and  quinine  in  combination,  with  very  good 
result.  Aromatic  sulphuric  acid  is  also  found  very  effi- 
cient for  this  purpose.  Or  at  times  zinc  oxide  is  used. 
Sponging  the  body  with  cold  or  warm  water,  or  with 
water  rendered  slightly  acid,  is  also  employed  bene- 
ficially. For  the  diarrhoea,  cod  liver  oil  combined 
with  the  hypophosphites  is  used  with  advantage. 
Where  these  fail,  however,  he  almost  invariably  finds 
the  following  successful : 

5-    Bismuth.      .....     grs.x. 

Morph.  sulph.      ....      gr.  j^g. 

M.     Sig.     To  be  taken  after  each  movement. 

To  relieve  the  cough,  opium  is  employed  only  as  a 
last  resort.  Chloroform  is  preferred,  the  inhalation 
of  a  few  drops  often  giving  complete  relief.  Coun- 
ter-irritation by  means  of  cups  is  employed  with 
great  benefit  when  local  pleurisies  occur. 

Besides  the  medicinal  treatment  of  phthisis,  Dm. 


PULMONARY    PHTHISIS.  77 

LOOMIS  resorts  to  various  hygienic  measures  which 
are  equally  important.  In  general  terms,  he  advises 
removal  to  a  climate  which  is  conducive  to  health,  at 
the  same  time  regulating  the  habits,  exercise,  occu- 
pation, etc.  Friction  over  the  chest  with  a  coarse 
towel,  practiced  night  and  morning,  is  also  advised 
with  much  benefit.  This  will  also,  in  many  instances, 
entirely  relieve  the  neuralgic  pains  which  are  fre- 
quently so  distressing.  A  plentiful  supply  of  fresh 
air  is  considered  highly  important,  but  all  exposure 
to  cold  must  be  carefully  avoided  ;  flannel  should  be 
worn  next  the  body  at  all  times.  As  regards  climate, 
he  can  give  no  absolute  rules  ;  this  must  be  decided 
by  the  peculiarities  of  each  particular  case,  and  by 
the  experience  of  the  patient  previous  to  the  phthis- 
ical development.  In  fibrous  phthisis,  however, 
when  shortness  of  breath  becomes  a  prominent  symp- 
tom, with  paroxysmal  cough,  vomiting,  and  occa- 
sional haemoptysis,  Dr.  LoOMis  recommends  the 
patient  to  seek  some  region  of  high  altitude,  where 
he  will  be  obliged  to  breathe  but  little,  such  as  is 
offered  in  Colorado.  With  this,  nutrition  is  to  be 
sustained  and  carried  to  the  highest  point,  pursuing 
at  the  same  time  a  life  of  regular  habits  with  plenty 
of  out-door  exercise.  This  he  has  often  found  to  be 
exceedingly  beneficial. 

Dr.  a.  a.  Smith  highly  recommends  the  follow- 
ing to  relieve  the  cough  in  phthisis,  when  it  is  desir- 
able to  avoid  the  use  of  opium  : 

5.    Spts.  chloroformi 

Acid,  hydrocyan.  dil.  .  .   aa3iss. 


78  PULMONARY   PHTHISIS. 

Tinct.  hyoscyami         .         .         .         5  ss. 
Aquae  camphorae  ad    .  .  .         §  iv. 

M.  Dose :  A  teaspoonful  in  water  §  ss.  every 
two  hours. 

Dr.  Alonzo  Clark  advises  that  successful  treat- 
ment must  be  assisted  by  climatic  effects,  with  abun- 
dance of  fresh  air  and  good  nourishment.  Other 
things  being  equal,  an  elevation  of  1500  feet  is  better 
than  at  the  sea  level.  A  dry  climate  is  to  be  desired, 
hence  the  sea  air  only  affords  temporary  benefit,  and 
then  is  apt  to  be  unfavorable.  He  considers  the  inte- 
rior more  suitable,  and  a  warm  climate  is  also  pre- 
ferred, as  in  cold  places  he  finds  that  the  patient  gets 
very  little  fresh  air,  unless  he  is  strong  enough  to  live 
out  of  doors,  hunting,  etc.  On  the  whole,  however. 
Dr.  Clark  becomes  more  and  more  disinclined  to 
send  patients  away  from  their  homes. 

In  addition,  he  also  advises /r/r//^;/  on  rising  in  the 
morning,  as  of  excellent  service  ;  the  entire  body 
being  briskly  rubbed.  For  this  purpose  he  finds  the 
hard  hand  of  a  laboring-man  the  best  means  of 
application  ;  failing  this,  a  flannel  may  be  used.  If 
the  patient  sleeps  in  a  warm  room,  it  is  a  good  plan 
to  have  the  body  sponged  over  at  night  and  wiped 
dry  with  a  towel  at  once.  The  inhalation  of  oxygen, 
a  gallon  at  a  time,  has,  in  his  judgment,  very  kindly 
effects.  For  the  loss  of  appetite,  out-door  exercise 
and  fresh  air,  together  with  friction,  is  very  beneficial. 
He  also  supplements  this  by  the  administration  of 
infusion  of  quassia  or  calumbo  ;  or  citrate  of  iron 
and  quinine   dissolved    in   a  little  water  and  lemon 


PULMONARY   PHTHISIS.  79 

juice  added  ;  or  compound  tincture  of  gentian  with 
a  little  sherry ;  all  are  considered  excellent  by  him. 
The  following  is  very  often  employed  at  this  hos- 
pital : 

]^.     Ferri  et  quiniae  citr.     .         .         .  3  i. 

Vini  xerici  .         .         .         .         ^ii. 

M.     Dose  :  A  teaspoonful. 
Also : 

5.     Tinct.  cinchonae  CO. 

Tinct.  gentianae  co.  .         .  aa  §  i. 

M.     Dose :     A  teaspoonful. 

In  the  summer  months  Dr.  Clark  prepares  a  very 
excellent  to?iic  thus:  Take  of  tansy  two  parts,  dind  of 
wormwood  one  part ;  place  in  a  common  wine-bottle, 
and  fill  with  sherry  zvine.  To  control  the  night 
sweats  he  gives : 

5.     Acid  sulph.  aromat.  .         .         .     gtt.  xv. 

Aquae  q.  s. 
Sig.  Dose,  three  times  daily. 

This  if  necessary  is  increased  to  gtt.  xx,  xxx,  or  xlv. 
Or  he  sometimes  prescribes  quinine^  in  doses  of  grs. 

In  using  quinia,  he  advises  that  to  obtain  benefit, 
the  effects  of  the  drug  must  be  produced.  In  other 
cases  he  gives  atropicE  siilph.,  gr.  y-J-o-tV  ^-t  night.  Or 
again,  he  finds  the  following  is  most  serviceable  : 

9-    Zinci  oxidi         ....         grs.  v. 
Ext.  hyoscyami         .         .         .        grs.'ii. 

Sig.  Dose. 

In  still  other  instances,  sponging  the  body  at  night 


80  PULMONARY    PHTHISIS. 

with  common  whiskey,  warmed,  and  to  which  has 
been  added  all  the  alum  or  borax  it  will  dissolve,  is 
very  efficient. 

For  the  diarrhoea,  he  prescribes : 

9.     Bismuthi  subnit.       .         .         .         grs.  x. 
Morph.  sulph.  .         .         .         gr.  ^^. 

Sig.    Dose. 

When  haemoptysis  is  present,  ergot  may  be  used 
r'i'h  a  certain  amount  of  benefit ;  but  Dr.  CLx\RK 
obtains  better  results  from  tying  off  some  of  the 
Moody  c.  g.,  placing  a  ligature  about  one  arm  for  a 
tvhile,  and  then  gradually  letting  it  free.  If,  how- 
ever, the  haemorrhage  continues  for  any  great  length 
of  time,  this  should  be  freed  and  the  opposite  arm 
tied,  and  thus  alternate.  In  regard  to  the  cough,  he 
considers  an  ordinary  cough  beneficial  and  should  be 
let  alone.  When  severe,  opiates  are  given.  Inhala- 
tion of  steam  is  also  employed  with  great  relief  to 
the  mucous  membrane. 

The  following  is  a  favorite  with  him  : 

5.     Ext.  opii  .         .         .         .         gr.  iss. 

Aquae     .....  §  i. 

M.      Sig:  To  be  inhaled  by  the  spray. 

In  other  cases  he  orders  the  following: 
]^.     Spts.  aether,  co. 

Tinct.  tolutan.  .         .  .        aa  gtt.  xv. 

M.     Sig  :  To  be  inhaled  from  a  warmed  cup. 

He  has  lately  been  prescribing  the  hypopJiospJiite 
of  lime,  in  doses  of  grs.  v.  three  times  daily,  and  con- 
tinued for  several  months  ;  and,  also,  a  dilute  solution 


PULMONARY   PHTHISIS.  8 1 

of  creosote  or  carbolic  acid,  of  the  strength  of  1-200,  to 
be  inhaled  in  the  form  of  a  spray  from  the  atomizer. 
For   an    expectorant    he  almost    invariably    pre- 
scribes : 

5-     Syrupi  senegae      .         .         .         .  31- 

Tinct.  opii  camph.        .         .  gtt.  xv.        ' 

M.     Sig:  Dose. 

Inhalation  of  the  benzoate  of  soda  is  a  remedy 
lately  employed  by  the  French,  which,  Dr.  Clark 
states,  has  given  some  very  remarkable  results. 

As  regards  the  diet^  this  he  would  have  of  the 
most  nutritious  kind.  When  the  patient's  appetite 
is  good,  that  is,  before  the  lungs  are  very  consider- 
ably diseased  and  he  is  able  to  be  up  and  about, 
plenty  of  fresh  air  is  advised,  together  with  an  abun- 
dance of  good  food.  The  character  of  the  food,  he 
directs,  should  be  to  a  certain  extent  oily,  consisting 
of  meat,  beef-steak  is  good,  and  milk,  or  cream,  oi' 
cod  liver  oil.  This  latter  he  administers  a  little  more 
freely  than  is  commonly  prescribed  ;  a  tablespoonfu] 
thrice  daily  is  considered  by  him  as  hardly  sufificient. 
He  also  advises  a  food  prepared  thus :  Take  one  pint 
of  wheaten  flour,  place  in  a  bag  and  boil ;  the  water 
to  be  changed  as  fast  as  it  becomes  loaded 
with  starch,  and  the  process  continued  until 
the  gluten  in  the  bag  forms  a  cake.  This  broken 
with  milk  Dr,  Clark  considers  the  best  food  for 
these  patients.  In  incipient  phthisis  he  orders  half- 
a-pint   of    cream  on   hominy  or  oatmeal,    or  with  a 

baked  apple,  to  be  taken  three  times  daily. 
6 


8^  t'ULMONARY   PHTHISIS. 

The  following  preparation  of  cod  liver  oil  is  con- 
stantly employed  at  this  hospital : 

9.     Olei  phosphorati  (i  per  cent.)  grs.  c. 

iEtheris  .         .         .         .  fl.  3  ii. 

Olei  morrhuae  q.s.  ad       .         .      fl.  3  xvi. 

M.     fl.   3  ss.  contains  gr.  ^V  ^^  phosphorus. 

Dr.  Austin  Flint  gives  quinine  for  the  high  tem- 
perature in  many  instances,  as  follows: 

5"     Quiniae  sulph.         .  .         .         grs.  xv. 

Sig:  Dose,  to  be  taken  in  the  morning. 

This,  together  with  grs.  v.  in  the  evening,  he  often 
finds,  controls  the  marked  exacerbations. 

Dr.  E.  G.  Janeway  advises,  in  regard    to  sending 
patients    away   from    home,  that    during  the  winter 
season   they  should    remove   to  another  climate ;  to 
the  South,  to  Colorado,  or  to  California.     Not,  how- 
ever, with  the  expectation  of  getting  well,  but   that 
they  may  be   in    a   climate  where  they  will  be  more 
comfortable,  while  they  do   live,  than  at  home.     By 
this    means  he  observes  that  patients  often  prolong 
life    from   three  to  five  years.     The  following  is  the 
formula  for  Dr.  Janeway's  cough  mixture: 
9.     Syrup,  tolutan. 
Syrup,  pruni  virg. 
Tinct.  hyoscyami 
Spts.  aether,  co. 

Aquae  .         .         .         .  aa  fl.  3  i. 

M.     Dose  :  A  teaspoonful. 

At  this  hospital,  when  in  patients    of  phthisis  the 
fever    proves    very  troublesome,  with    night  sweats, 


PULMONARY   PHTHISIS.  83 

the  following  is  prescribed,  in  many  instances,  with 
the  best  effect ;  the  temperature  falls,  the  pulse 
becomes  more  natural,  and  the  accompanying  symp- 
toms are  temporarily  alleviated. 

5.    Acid,  sulphur,  dil.  .         .  gtt.  xx. 

Quinae  sulph.  .         .  .  grs.  v. 

M.     Sig.    Dose,  every  three  hours. 

When  there  is  much  gastric  disturbance,  with 
dyspeptic  symptoms,  etc.,  the  following  is  found  of 
excellent  service  : 

^.      Ferri  et  bismuthi  citr.        .          .  3  iv. 

Aquse ^iv. 

M.     Dose:  One  or  two  teaspoonfuls.  "* 
In  children,  the  following  cough  mixture  is  used : 

9.    Tinct.  opii  camph. 

Spts.  ammon.  aromat.  .  aa  3  v. 

Ext.  ipecac.           .         .  .  .      3  ss. 

Syrup,  pruni.  virg.         .  .  .        §  i. 

Aquae    .         .         .         .  .  .      §  vi. 

M.     Dose  :  A  teaspoonf  ul. 

PRESBYTERIAN    HOSPITAL. 

Dr.  F.  a.  Burrall  places  the  patient  on  the  use 
of  stimulants,  tonics,  and  cough  mixtures.  For  the 
dyspnoea,  he  finds  that  quebracJw  affords  great  relief, 
in  many  instances  when  all  other  remedies  have 
failed  ;  given  thus  : 

9.      Ext.  quebracho  fl.         .         .   m.  xxx-xl. 
Sig.    Dose,  every  three  hours. 

*  Ferri  et  bismuthi  citras  contains  equal  parts  of  citrate  of  bismuth 
and  ammonio-citrate  of  iron. 


84  PULMONARY   PHTHISIS. 

By  this  means  the  respirations  are  lessened  from 
three  to  eight  per  minute,  and  the  breathing  rendered 
much  easier. 

In  many  cases  of  patients  in  the  third  stage  of 
phthisis  with  marked  anaemia,  rapid  emaciation,  loss 
of  appetite,  vomiting,  hectic,  and  frequent  and  ex- 
hausting night-sweats,  when  the  usual  treatment  of 
cod-liver  oil  and  iron,  combined  with  the  most  nutri- 
tious diet,  is  unavailing,  cneinata  of  defibrinatcd  blood 
are  administered  with  great  benefit.  The  injections 
are  given  at  bed-time,  usually  commencing  with  §  iv. 
of  defibrinated  blood  to  which  has  been  added  cJdoral 
hydrate  grs.  iv.  The  general  treatment  is  also  con- 
tinued, or  a  diet  of  milk  and  beef-tea  ordered.  After 
several  injections  have  been  practiced,  if  the  rectum 
does  not  tolerate  this  amount,  it  is  reduced  to  5  ii.; 
by  continuing  this  for  a  few  days,  and  then  adding 
tincture  of  opium  gtt.  v.  to  each  §  iv.  of  the  blood, 
the  full  amount  is  usually  retained  without  difficulty. 
If  constant  vomiting  is  present,  cerium  oxalate,  grs. 
iv-vi.  every  7iight  and  morning,  is  given  with  great 
advantage.  Should  the  vomiting  still  persist  in  spite 
of  all  measures  to  control  it,  the  injection  is  given 
every  five  or  six  hours,  and  viilk  and  lime-water 
administered  in  very  small  quantities.  By  this  means 
the  vomiting  is  often  entirely  subdued.  In  such 
cases,  to  prevent  irritation,  the  rectum  should  be 
washed  out  once  in  twenty-four  hours,  and  gtt.  ii-iii. 
of  laudanum  added  to  the  injection  as  the  irritation 
increases.  As  a  result  of  this  treatment,  it  is  found 
that  in  many  cases  the  appetite  returns,  the  vomiting 


PULMONARY   PHTHISIS.  85 

disappears,  the  patient  becomes  less  anaemic,  night 
sweats  diminish  in  frequency,  the  body  weight  in- 
creases, and  a  steady  improvement  in  the  general 
condition  of  the  patient  follows. 

In  young  women  of  phthisical   tendency,   where 
there   is  a  condition  of  anaemia  and  chlorosis.  Dr. 
A.  H.  Smith  prescribes  the  following  tonic: 
9-    Hydrarg.  chlor.  corros.    .  .      grs.   i-ii. 

Liq.  arsenisi  chlor.         .         .         .     fl.  §  i. 
Tinct.  ferri  chlor. 

Acid,  hydrochlor.  dil.  .       aa  fl.  3  iv. 

Syrupi  .         .         .         .  fl.  §  iii. 

Aquae  ad      .         .         .         .         .     fl.  5  vi. 

M.    Dose :  A  dessertspoonful  in  a  wineglassful  of 

water,  after  meals. 

This  often  affords  the  greatest  benefit,  the  general 
condition  and  body-weight  of  the  patient  improving 
in  a  remarkable  manner.  It  should  not  be  given  for 
a  longer  period  than  two  weeks  at  a  time. 

NEW  YORK  HOSPITAL. 

In  phthisis  associated  with  syphilis,  so-called  syph- 
ilitic phthisis.  Dr.  W.  H.  Draper  places  the  patient 
immediately  under  specific  treatment.  In  one  case 
with  marked  syphilitic  history,  the  patient  having 
also  rheumatism  with  subjective  epileptic  attacks,  he 
ordered  : 

5.   Hydrarg.  biniodid.       .         .         .       gr.  A- 
Potass,  iodidi       .         .         .         grs.  x-xv. 
Si^.    Dose,  three  times  daily. 


86 


PULMONARY   PHTHISIS. 


Under  this  treatment  the  symptoms  rapidly  abated. 
In  another  syphilitic  case  the  patient  had  suffered 
from  laryngeal  and  pulmonary  phthisis  for  eight 
years ;  although  late  in  the  disease,  yet  the  same 
treatment  was  prescribed,  followed  by  considerable 
amelioration  of  the  symptoms,  and  marked  improve- 
ment constitutionally.  The  following  is  an  excellent 
method  of  administration,  and  very  much  used  at 
this  hospital : 

5-    Hydrarg.  biniodid.      .         .         .         gr.  i. 


Potass,  iodidi 
Syr.  aurant.  cort. 
Tinct.  card.  comp. 
Aquae  q.  s. 


.3v. 

3ii. 
3iv. 


M. 


CHARITY   HOSPITAL. 

Dr.  Beverly  Robinson  administers  the  compound 
syrup  of  the  hypophosphitcs,  four  times  daily,  for  sev- 
eral months.  This  he  considers  the  most  efficient 
remedy  in  the  treatment  of  catarrhal  phthisis.  When 
practicable,  however,  he  prefers  to  use  the  Jiypophos- 
phites  in  doses  of  grs.  x.,  taken  in  a  teacupful  of  milk 
upor^  rising  in  the  morning.  The  following  com- 
bination is  used  at  this  hospital : 

5--    Calcii  hypophosphitis  .         grs.  cclvi, 

Sodii  "  .         .         grs.  cxcii. 

Potasii         "  .         .     grs.  cxxviii. 

Ferri  sulphatis     .         .         .     grs.  clxxxv. 
Acidi  hypophosphoroci  (i  .036)         fl.  3  ix. 


PULMONARY   PHTHISIS.  "  8/ 

Sacchari       .         .         .         .         .        §  xii. 
Aquae  q.  s.  ad.     .         .         .         fl.  5  xv^iii. 

M.     Dose  :  A  teaspoonful. 

Cream  and  whiskey  are  also  given  with  the  diet.  If 
this  destroys  the  appetite,  he  substitutes  small  doses 
of  cod  liver  oil  instead,  combined  with  the  hypo- 
phosphites.  When  bloody  sputa  becomes  frequent, 
he  gives  ext.  ergotce  fl.,  in.  x.  If  the  haemorrhage  is 
more  profuse  the  dose  is  increased;  and  when  abundant 
he  administers  ergot  in  3  i-  doses,  p.  r.  n.  With  this, 
small  pieces  of  cracked  ice  are  swallowed  constantly. 

If  night-sweats  become  troublesome,  Dr.  ROB- 
INSON often  controls  them  by  gtt.  v-x.  of  tinct, 
belladonncB,  given  at  bedtime.  Or  he  sometimes 
uses  the  alkaloid,  commencing  with  atropiiie, 
gr.  :j-iy  hypodennically.  This  he  finds  more  effectual. 
If,  however,  it  fails  to  afford  relief,  he  then  resorts  to 
large  doses  of  dilute  or  aromatic  sulphuric  acid,  given 
in  the  acid  infusion  of  roses.  This,  he  advises,  should 
be  taken  through  a  glass  tube  to  protect  the  teeth, 
and  the  mouth  washed  after  swallowing.  In  his 
experience  quinine  does  not  arrest  the  night-sweats 
of  phthisis.  To  control  the  fever,  however,  he  finds 
it  very  serviceable.  For  this  purpose  Dr.  Robinson 
begins  with  qiiinice  sidpJi.  grs.  v.  three  times  daily. 
He  then  increases  the  dose,  as  indicated,  to  grs. 
x-xv.  For  the  cough,  he  directs  that  opiates  should 
never  be  used  until  absolutely  compelled.  He  first 
tries  chlorodyne,  administered  as  follows : 

9.    Liq.  chloroformi  co.     .         .         gtt.  x-xx. 
Sig.     Dose,  p.  r.  n. 


ss  PULMONARY   PHTHISIS. 

This  is  considered. by  him  as  superior  to  any  other 
anodyne  for  the  cough  of  phthisis.  Other  means 
are,  however,  employed  at  this  hospital.  In  many 
cases,  relief  is  obtained  by  the  administration  of 
grindelia  robusta.  Or,  atropia  is  sometimes  used 
with  benefit,  in  doses  of  gr.  ^^-^  and  upward. 
Hydrocyanic  acid  and  potassium  cyanide  are  service- 
able in  certain  instances,  but  they  are  found  not  to 
exercise  any  decided  influence  when  administered  in 
moderate  doses.  Moj'pJiiay  as  a  rule,  always  gives 
immediate  relief,  but  frequently  causes  nausea.  The 
following  is  found  to  be  of  greater  general  value,  and 
its  administration  is  also  devoid  of  any  nauseating 
effect : 


5.    Chloral.*  hydratis 

. 

grs.  X. 

Aquae       .... 

• 

q.  s. 

M.     Sig.     Dose. 

When    the   sputa   is   abundant. 

Dr. 

Robinson 

ives  : 

5..   Aquae  creosoti  (U.  S.  P.)    . 

• 

§ss. 

Sig.     Dose. 

He  finds  this  exceedingly  serviceable,  besides 
tending  to  diminish  the  frequency  of  the  cough. 
For  the  appetite,  when  other  means  fail  he  places 
most  reliance  on  nux  vomica.  Counter  irritation  is 
at  times  resorted  to,  preferably  by  iodine,  as,  besides 
being  a  good  local  remedy,  he  also  attributes  its 
beneficial  influence  to  effects  on  the  respiratory  tract 
by  inhalation.  Where,  however,  the  phthisis  has 
originated    from  acute  lobar  pneumonia,  he  uses   a 


PULMONARY    PHTHISIS.  ^      89 

succession  of  camphorated  fly-blisters ;  the  camphor 
sprinkled  over  the  cantharides,  he  advises,  makes  its 
effects  innocuous  as  regards  the  kidneys  and  bladder. 
In  tubercular  phthisis,  associated  with  general 
tuberculosis,  to  control  the  fever  Dr.  Robinson 
applies  iced  flannel  cloths,  well  wrung  out  and  folded 
twice,  constantly  over  the  abdomen,  until  the  body 
temperature  is  reduced  to  the  normal.  He  also 
makes  use  of  the  following  with  great  advantage  : 

]^.     Pulv.  digitalis         .... 

Pulv.  quiniae  sulph.        .  .  aa  gr.  i. 

Pulv.  opii       ....  gr.  ss. 

M.  et  ft.  pil.  No.  i. 
Sig.     To  be  taken  every  four  hours. 

For  the  sweating,  he  administers  hypodermics  of 
atropia,  as  usual,  as  often  as  the  abundance  of  per- 
spiration requires.  After  the  fever  has  considerably 
subsided,  an  emulsion  of  cod  liver  oil  is  given  and  con- 
tinued for  a  long  time.  On  this  plan  he  has  obtained 
very  excellent  results.  The  following  is  used  at  this 
hospital  :  ' 

J^.    Olei  morrhuae 

Aquae  calcis  .         .         .   aa  fl.   ?  viii. 

Olei  cinnamomi     .         .         .  gtt.  x. 

M.     Dose  :  A  tablespoonful. 

As  an  expectorant,  the  following  mixture  is  /ery 
frequently  employed : 

!p.    Tinct.  sanguinar.        .         .         .         fl.  3  i. 
Tinct.  opii  camph. 
Syr.  scillae 


90  PULMONARY   PHTHISIS. 

Syr.  tolutan.      .         .         .  aa  fl.  3  ii. 

Aquae  q.  s.  ad.  .  .         .        fl.  3  ii. 

M.     Dose  :  A  teaspoonful. 

In  regard  to  transfusion,  Dr.  J.  W.  HowE  has 
practiced  it  successfully  both  of  milk  and  of  blood, 
and,   in  some  cases,  with  very  marked  benefit. 

ROOSEVELT  HOSPITAL. 

Dr.  Francis  Delafield's  treatment  is  in  a  great 
measure  constitutional,  by  the  administration  of 
tonics  and  cod  liver  oil,  and,  if  necessary,  a  change 
of  climate.  In  young  women  of  phthisical  develop- 
ments when  there  is  a  condition  of  marked  emacia- 
tion, anaemia,  chronic  diarrhoea,  and  generally  weak- 
ened constitution,  he  considers  the  immediate  indi- 
cation is  to  build  up  the  general  system  by  the  use 
of  iron,  combined  with  the  inhalation  of  oxygen. 
For  the  diarrhoea,  he  administers : 

9.     Acid,  hydrochloric.  .         .     gtt.  xx. 

Tinct.  opii  ....      gtt.  iii. 

M.     Sig.     Dose,  four  times  daily. 

By  this  means,  combined  with  good  food,  etc., 
considerable  improvement  often  follows.  In  other 
instances,  at  this  hospital,  the  following  is  found 
very  serviceable  in  checking  the  diarrhoea  of  phthisis : 

]^.    Resin,  terebinth.  .         .         .     grs.  iii. 

Argenti  nitrat. 

Opii  .         .         .         .         .  aa  gr.  J. 

M.  ft.  pil.  No.  i. 
Sig.     To  be  taken  as  needed. 


PULMONARY   PHTHISIS.  QI 

If   there  is   much  fever,  with  more  or  less  night- 
sweats  present,  Dr.  Delafield  often  prescribes : 
9-    Acid,  sulph.  aromat.  .  .    m.  xx. 

Quiniae  sulph.       ....     grs.  v. 
M.   Sig.     Dose,  every  three  hours. 
Zi7ic  oxide  and  belladonna  are  also  used  very  effi- 
ciently, at  this  hospital,  for  the  night-sweats ;  given 
thus : 

9-    Zinci  oxidi  .         .         .      grs.  xxxvi. 

Ext.  belladonnae  .         .  grs.  vi. 

Ext.  gentianae  .         .         .         q.  s. 

M.    ft.  pil.  No.  xii. 
Sig.     Take  one  at  night. 

To  prevent  putrefaction  of  the  secretions,  he 
employs  the  systematic  inhalation  of  carbolic  acid,  by 
means  of  the  atomizer,  or  vaporized  ;  care  being 
taken  that  the  inhalation  shall  penetrate  to  the 
smaller  bronchial  tubes.  To  diminish  the  bronchial 
secretions,  when  abundant,  he  finds  the  mineral 
acids  most  useful,  usually  giving  acidi  sulphuric,  dil., 
m.  XV.  four  times  daily.  If  this  fails,  he  tries  bella- 
donna, preferring  the  sulphate  of  atropia  ;  or  ipecac, 
giving /?//z7.  ipecac.gr.  i.  four  times  daily.  The  fol- 
lowing cough  mixtures  are  very  extensively  employed 
at  this  hospital : 

^.    Potass,  iodidi  .         .         ,     "     .      3ii. 

Spts.  aether,  co. 

Tinct.  hyoscyami  .         .         .  aa  3  vi. 

Syrup,  tolutan.       .         .         .         .       5  i* 
Aquae  .         .         .         .         .     §  iii. 

M.     Dose  :  A  teaspoonful. 


92  PULMONARY    PHTHISIS. 

5.    Ext.  pruni  virg.   fl.  .  .  .     3  iii. 

Sol.  potass,  cyanidi  (gr.  ii.-3i.) 
Sol.  morph.  sulph.  (Magendie)     .    aa  3  ss. 
S.yrupi  simp.  .         .         .  .     S  xxviii. 

M. 

For  the  aphthae  of  phthisis  the  following  wash, 
which  is  at  the  same  time  antiseptic  and  stimulant, 
is  used  with  gratifying  results : 

9.    Quiniae  sulph.  .         .         .         .    gr.  i. 

Olei  piperis  nigris  .         .  gtt.  i. 

Aquae  .  .  .  .  .        §  i. 

M  Sig.  May  be  applied  with  a  brush,  or  the 
Tiouth  rinsed  with  it. 

MOUNT  SINAI  HOSPITAL. 

The  inhalation  of  the  carbolic  acid  spray  is  prac- 
ticed at  this  hospital  with,  in  certain  particulars, 
very  excellent  service.  A  solution  containing  two 
per  cent,  of  the  acid  is  employed.  The  most  impor- 
tant effect  of  the  inhalation  is  to  reduce  the  temper- 
ature, in  some  cases  two  or  three  degrees ;  it  also 
increases  the  amount  of  expectoration  and  checks 
the  fetor  of  the  sputa.  Where  it  acts  as  an  irritant 
salicylic  acid  is  sometimes  substituted,  but  with  less 
influence  on  the  temperature. 


LARYNGEAL  PHTHISIS. 


Definition. — A  chronic  ulcerative  process  devel- 
oped in  the  mucous  membrane  of  the  larynx,  slow  in 
progress,  and  usually  occurring  in  connection  with 
pulmonary  phthisis ;  characterized  by  progressive 
emaciation,  change  in  the  quality  of  the  voice,  more 
or  less  dysphagia,  cough  and  expectoration. 

NEW  YORK  HOSPITAL. 

Dr.  W.  H.  Draper  calls  attention  to  the  fact, 
that  in  treating  pati(;nts  of  this  disease  they  are  often 
mistaken  for  cases  of  local  laryngitis,  as  the  lung 
lesion  is  not  at  all  in  proportion  to  the  constitutional 
symptoms  which  accompany  it.  The  larynx  is  con- 
sequently subjected  to  a  long  and  painful  course  of 
treatment  with  local  applications,  stimulants,  etc., 
until  finally,  the  patient  growing  rapidly  worse,  a 
time  arrives  when  it  is  discovered  that  the  more 
serious  trouble  is  pulmonary  phthisis.  For  the  local 
affection,  all  irritation  to  the  parts  must  be  carefully 
avoided.  If  the  patient  be  a  stone-cutter,  or  a  weaver, 
thi:.  occupation  must  be  given  up.  Or  if  a  public 
speaker,  or  obliged  to  talk  very  loudly  for  any  length 
of  time,  this  must  be  stopped.  To  relieve  the  pain 
Dr.  Draper  administers  opium  either  by  the  mouth 

93 


94  LARYNGEAL   PHTHISIS. 

or  hypodermically  ;  or  he  makes  use  of  the  following 
topical  application  ; 

J),.     Morphiae  sulph.    .         .         .         •     gi*-  i- 
Cretae  praep.  ....  grs.  ii. 

M. 

This  he  applies  by  insufflation  directly  on  the  ulcer. 
In  all  cases,  however,  he  finds  that  treatment  is  very 
apt  to  be  difficult,  on  account  of  the  extreme  pain 
from  which  the  patient  suffers  in  movement  of  the 
part.  For  the  lung  disease  he  administers  constitu- 
tional treatment,  consisting  of  fresh  air,  good  food, 
freedom  from  anxiety,  cod  liver  oil,  etc.,  together  with 
tonics  and  stimulants. 

BELLEVUE  HOSPITAL. 

For  cleansing  the  part,  preparatory  to  more  special 
treatment.  Dr.  F.  H.  Bosworth  uses  the  following 
solution  : 

9.     Acid,  carbol.  cryst.  .  .         grs.  xii. 

Sodii  bicarbon. 

Sodii  biborat.         .         .         aa  grs.  xxiv. 
Glycerinae      ....  3  iss. 

Aquae  rosae  ad        .         .         ,  §  viii. 

M.     Sig.   Spray. 

This  he  applies  in  the  form  of  a  spray,  repeated 
several  times  until  the  ulcerated  parts  are  thoroughly 
cleansed.  If  much  pain  or  irritation  is  produced,  he 
reduces  the  strength  of  the  solution  or  changes  it ; 
in  the  latter  instance  using  the  following : 

9.     Sodii  salicylat.         .         .         .         grs.  x. 


LARYNGEAL   PHTHISIS.  95 

Sodii  biborat.  .         .         .         .3 

Glycerinae       ..... 

Aquae  rosae  ad         .         .         .  5  viii 

M.     Sig.    Spray. 

The  former  solution  is,  however,  greatly  preferred 
by  him.  He  then  applies  an  anodyne,  as  a  rule,  es- 
pecially if  pain  has  been  caused  by  any  of  the  pre- 
vious applications.  For  this  purpose.  Dr.  Bosworth 
employs  a  five  per  cent,  solution  of  morphia^  with  the 
addition  of  sodium  or  potassium  carbonate  to  give  it 
an  alkaline  reaction,  and  a  small  portion  of  mucilago 
acaciae.  He  next  uses  an  astringent,  being  guided 
in  his  selection  somewhat  by  the  effect  and  toler- 
ance ;  of  these,  the  following  are  in  the  order  of  his 
preference  : 

Zinci  sulphat.         .         .  .    grs.  x-Ji. 

Argenti  nitrat.      .  .         grs.  iii.-v-J  i. 

Zinci  chloridi         .  .  .     grs.  iii-§i. 

Acid,  tannici  et  glycerinae     .  3i"Si- 

Liq.  ferri  persulph.         .         .     m.  xx-Ji. 

Finally,  he  applies  iodoform  to  the  surface  of  the 
ulcer  for  its  specific  action,  its  effect  being,  in  many 
instances,  most  gratifying.  The  formula  generally 
employed  by  him  is  as  follows  : 

^.     Morphiae  sulph.  .  .         .  grs.  x. 

Acid,  tannici  .  .         .  .    3  ii. 

lodoformi       .  .  .         .  .   3  vi. 
M. 

Sometimes  he  uses  a  saturated  solution  of  ether 
rn.  xl-  5  i.     For  applying  these,  the  powder-insufHa- 


96  LARYNGEAL   PHTHISIS. 

tor  or  the  spray  is  always  preferred  ;  the  brush, 
sponge,  etc.,  necessarily  touch  the  diseased  and  sen- 
sitive parts,  which  he  considers  harmful,  and  advises 
that  in  all  cases  the  treatment  must  be  accompanied 
with  the  least  possible  irritation.  Previous  to  the 
stage  of  ulceration  the  treatment  is  the  same  with  the 
exception  of  the  iodoform,  which  is  used  for  its  spe- 
cific action  in  ulceration.  Inhalations,  as  a  rule,  he 
considers  of  little  or  no  value,  and  the  steam  atomizer 
as  positively  harmful.  For  using  medicated  solutions 
during  the  intervals  of  treatment,  he  finds  the  little 
cologne  atomizer  of  the  toilet  most  serviceable.  The 
carbolized  alkaline  solution  is  employed,  to  which,  if 
a  sedative  is  indicated,  he  adds  3  i  of  Magendie's  solu- 
tion of  morphia  to  3  i.  At  the  commencement.  Dr. 
BOSWORTH  believes  it  necessary  to  give  daily  treat- 
ment, or,  in  the  earlier  stages,  as  of.ten  as  every  sec- 
ond day.  If  the  progress  of  the  case  be  favorable, 
once  a  week,  and  later,  once  in  two  weeks,  is  found 
to  be  sufficient.  All  these  measures  failing  to  relieve 
tracheotomy  is  to  be  entertained.  This  he  considers 
justifiable  as  a  remedial  measure  when  local  remedies 
are  unavailing,  and  before  it  is  demanded  by  dyspncea 
from  cedema  and  stenosis.  In  addition  to  the  above 
treatment,  constitutional  means  are  employed,  such 
as  cod  liver  oil,  iron,  quinine,  etc.,  to  build  up  the 
general  condition  of  the  patient. 


SPASMODIC   ASTHMA-HAY 
FEVER. 


Definition. — An  affection  characterized  by  spas- 
modic contraction  of  the  bronchial  tubes,  causing 
intense  dyspnoea,  attended  with  loud  wheezing",  great 
anxiety,  and  the  sense  of  suffocation;  terminating  by 
a  gradual  subsidence  of  the  attack,  with  cough,  at 
first  dry,  then  accompanied  by  expectoration  of  mu- 
cus varying  in  amount  and  appearance.  Hay 
Fever. — A  catarrhal  affection  occurring  during  the 
months  of  May,  June,  and  July,  and  generally  ascribed 
to  the  emanations  from  newly-mown  hay,  or  the  vari- 
ous flowering  grasses;  disappearing  spontaneously,  it 
recurs  annually  at  the  specified  period. 

BELLEVUE  HOSPITAL. 

The  treatment  of  spasmodic  asthma  is  necessarily 
very  variable,  according  to  the  peculiarities  of  each 
individual  case. 

Dr.  Alonzo  Clark  sometimes  directs  the  patient 
to  inhale  the  smoke  of  stramoniujn  leaves;  this  may 
be  blown  into  a  receiver  (a  hat)  until  it  becomes 
filled,  and  then  breathed.  In  other  cases,  he  finds 
that  inhalation  of  the  fumes  of  burning  nitre  paper 
is  more  serviceable.  Again,  he  frequently  obtains 
relief  by  the   smoking  of  tobacco^   given  to   produce 

97 


98  SPASMODIC   ASTHMA — HAY   FEVER. 

sickness  ;  but  this  remedy  is  of  benefit  only  to  those 
who  do  not  use  it  habitually.  EtJicr  or  chloroform 
inhaled  are  also  beneficial,  but  attended  with  more 
or  less  danger.  In  the  greater  number  of  cases, 
however,  he  considers  nitrite  of  amyl  more  effica- 
cious, and  finds  that  it  will  almost  invariably  cut 
short  the  attack  at  once.      He  gives: 

]J.     Amyli  nitriti  ....    gtt.  v. 

Sig.     To  be  inhaled  from  a  cloth  or  sponge. 

For  a  radical  cure.  Dr.  Clark  places  more  reliance 
upon  iodide  of  potassium,  and  believes  it  to  be  supe- 
rior to  any  other  remedy.  This  he  gives  with  mod- 
erate freedom  for  some  time,  and  obtains  complete 
and  permanent  cure  in  about  one-half  the  cases. 
When  all  remedial  agents  fail  he  finds  but  one  re- 
maining resource  which  will  invariably  give  relief, 
namely,  travel  and  a  change  of  residence.  Dr. 
Clark  does  not  doubt  that  there  is  a  spot  some- 
where in  the  world  for  each  asthmatic  patient,  where 
the  disease  will  disappear  never  to  return.  As  a 
general  rule,  he  has  found  that  the  sea  will  accom- 
plish this,  but  not  always. 

At  this  hospital,  for  the  autumnal  attacks  of  spas- 
modic asthma,  especially  if  associated  with  pulmonary 
emphysema,  the  following  prescription  is  employed, 
and  found  to  be  very  serviceable: 

IJ.     Potass,  iodid 3  ii- 

Spts.  aether,  co.  .         .         .3  ss. 

Syr.  pruni  virgin.  .         .         .         3  iv. 

M.    Sig.     A  teaspoonful  four  times  daily. 


SPASMODIC   ASTHMA — HAY   FEVER.  99 

Dr.  Loomis  advises  that  the  exciting  cause,  what- 
ever it  be,  should  receive  prompt  attention,  aiming  to 
remove  it.  When  this  is  not  practicable,  or  fails,  the 
free  admission  of  air  is  obtained  and  such  a  position 
of  the  patient  secured  which  affords  greatest  freedom 
to  respiration.  His  medicinal  treatment  varies.  He 
considers  it  of  importance  to  inquire  of  the  patient 
what  remedy  has  formerly  been  of  benefit.  In  some 
he  finds  ipecac  very  serviceable,  and  has  occasionally 
given  complete  relief  by  a  single  full  dose.  In  others 
opium,  stramoniinn,  chlorofonn,  or  the  fumes  of  nitre 
paper  are  most  beneficial.  Of  these  he  prefers  mor- 
phia i7i  doses  of  gr.  ss.,  hypodermically.  Or,  some- 
times a  combination  of  atropine  with  morphia  affords 
speedier  relaxation  than  either  drug  alone.  In  some 
of  the  warcis  at  Bellevue  the  following  is  often  used 
with  very  satisfactory  results  : 

^.    Spts.  aether,  co. 

Liq.  morph.  sulph.  (U.  S.  P.)       .     aa.  §  i. 

M.    Dose:  A  teaspoonful  to  a  tablespoonful. 

Strong,  black  coffee  (without  sugar  or  milk)  is  also 
employed  by  Dr.  Loomis  with  advantage,  given  as 
hot  as  the  patient  can  bear  it  and  upon  an  empty 
stomach.  Alcohol  similarly  taken  (hot  and  strong 
and  to  intoxication)  is  also  found  of  great  value.  His 
prophylactic  treatment  consists  in  strict  attention  to 
hygienic  and  dietetic  regulations.  He  mentions  the 
fact  that  these  patients  are  very  apt  to  be  dyspeptic, 
hence  this  condition  should  receive  all  necessary  care 
and  medication.  Tonics,  cod-liver  oil,  and  iron  are  also 
administered,  where  there  is  much  anaemia  and  mal- 


lOO       *     SPASMODIC  ASTHMA — HAY   FEVER. 

nutrition*  In  some  cases  by  giving  grs.  v-x.  of  qui- 
nine daily,  he  has  been  able  to  ward  off  the  attack; 
but  the  withdrawal  of  the  drug  was  immediately 
followed  by  a  return  of  the  symptoms.  Finally, 
when  the  paroxyms  are  excited  by  the  inhalation  of 
irritant  substances,  the  weather,  atmosphere,  etc., 
Dr.  Loomis  advises  a  removal  to  some  other  locality, 
regarding  which,  however,  each  patient  must  ascer- 
tain for  himself. 

Dr.  W.  H.  Thomson  highly  recommends  the 
following  in  those  cases  of  asthma  associated  with 
and  dependent  upon  bronchitis,  and  with  no  dyspep- 
tic symptoms: 

1^.    Tinct.  belladonnae         .         .         .  3  i- 

Spirit,  aether,  co.  .  .         .       3  vi. 

M.  To  be  added  to  5  vi.  of  an  emulsion  of  lin- 
seed oil  and  gum  tragacanth,  and  flavored  with  oil  of 
wintergreen. 

Dose  :  A  tablespoonful  three  times  daily,  one  and 
one-half  hours  after  meals  ;  the  last  dose  at  bedtime. 

In  addition  to  this  he  also  gives  : 

]^.    Potass,  iodid.      ....       grs.  v. 

Liq.  potass,  arsenit.     .         .         .     gtt.  iv. 

Aquae  ad.  .         .         .         .  3  ss. 

M.     Sig.     Dose,  three  times  daily. 
Dr.  Austin  Flint  finds  quebracho  of  very  great 
benefit  for  relieving  the  dyspnoea.     He  gives  : 

]^.     Ext.  quebracho  fl.      .         .         .       m.  xv. 
Sig.     Dose,  every  hour. 

In    some   cases,  relief  from  the  most  severe  par- 


SPASMODIC   ASTHMA — HAY   FEVER.  lOI 

oxy»m  is  almost  instantaneous  ;  at  times  it  fails, 
however,  and  only  morphia  is  of  service.  In  the 
asthma  of  emphysema  and  bronchitis  he  admxinisters 
cod  liver  oil  and  tonics  for  a  considerable  period  of 
time.  Quebracho  he  also  finds  equally  valuable  in 
these  cases.  Regarding  climate  Dr.  Flint  considers 
Kansas  and  the  surrounding  country,  more  especially 
Colorado,  as  particularly  beneficial  to  these  patients. 
Hay  Fever. — In  the  experience  of  Dr.  Alonzo 
Clark  very  little  good  is  to  be  found  in  remedial 
agents.  As  a  palliative  measure  he  some- 
times derives  temporary  benefit  by  moistening  the 
nares  with  a  iveak  solution  of  qiiinia  (snuffed  up 
the  nose),  and  protecting  the  air  passages  by  an  inha- 
lation of  a  spray  of  the  same  solution.  In  other 
instances,  dilute  hydrocyanic  acid^  in  doses  of  gtt.  i-ii., 
is  given  with  benefit.  Absolute  cure,  however,  is  to 
be  obtained  almost  solely  by  a  change  of  locality, 
thus  avoiding  the  poison  which  produces  the  disease. 
For  this  object.  Dr.  Clark  finds  nearly  the  entire 
White  Mountain  region  of  this  character.  Fire 
Island  he  also  considers  a  good  remove.  Also  some 
of  the  mountain  regions  of  Pennsylvania,  and  of  the 
West,  and  along  the  shores  of  Lake  Superior, 

PRESBYTERIAN  HOSPITAL. 

Dr.  a.  H.  Smith  has  had  excellent  results  from 
the  administration  of  quebracho.  In  many  instances 
where  the  paroxysms  of  dyspnoea  are  intense  in  their 
severity,  and  other  means  fail,  this  drug  often  proves 
of  greatest  service.      In  such  cases  he  usually  gives 


102  SPASMODIC  ASTHMA — HAY   FEVER. 

it  in  doses  of  m.xl.  of  the  fluid  extract.  Sometimes 
with  orthopnoea,  cyanosis,  and  very  labored  breath- 
ing present,  perfect  relief  has  followed  in  a  very 
short  time.  Also,  in  many  cases,  the  attacks  became 
less  frequent  until  they  finally  completely  disap- 
peared. In  one  instance,  where  iodide  of  potassium, 
stramonium,  nitre  papers,  amyl  nitrite,  belladonna, 
chloral,  etc.,  had  all  been  tried  without  avail,  he 
gave  : 

^.      Ext.  quebracho  fl.  .  .  m.  xx. 

Sig.    Dose,  three  times  daily. 

Immediate  relief  followed.  Another  patient  had 
suffered  from  spasmodic  asthma  of  many  years' 
standing  ;  quebracJiOy  in  3  ss.  doses,  tJiree  times  daily , 
was  at  once  given,  and  afforded  marked  and  perma- 
nent relief.  Dr.  Smith  has  also  found  this  drug- 
useful  in  almost  every  form  of  dypsncea,  and  has  no 
doubt  that,  in  many  cases,  it  will  promptly  fulfill  this 
indication.  As  yet  he  has  no  evidence  of  any  ten- 
dency to  produce  unfavorable  after  effects. 

NEW  YORK  HOSPITAL. 

Dr.  W.  H.  Draper  frequently  uses  quebracho 
with  advantage,  but  he  considers  opium  the  only 
sure  relief.  This  he  gives  by  hypodermic  injection, 
thereby  causing  less  disturbance  than  by  the  stom- 
ach ;  beginning  with  small  doses,,  as  follows,  and 
gradually  increasing : 


SPASMODIC   ASTHMA — HAY   FEVER.  I03 

5.     Morphiae  sulph.       .         .         .  grs.  Ixxx. 
Aquae  destil.  carbol.  .         .         fl.  5  v. 

M.  et  filt. 

Dose  :  two  to  four  minims. 
This  invariably  affords  relief. 

ST.  FRANCIS'  HOSPITAL. 

When  recurring  asthma  is  present  as  a  symptom 
of  Bright's  disease,  Dr.  J.  H.  RiPLEY  obtains 
prompt  relief  by  the  administration  of  hydragogue 
cathartics. 

ST.  LUKE'S  HOSPITAL. 

Dr.  G.  G.  Wheelock  finds  quebracho,  in  doses 
of  ni.xx-xl.  of  the  fluid  extract^  of  marked  value  in 
the  dypsnoea  of  asthma. 

MT.  SINAI  HOSPITAL. 

In  some  cases  morphia  hypodermically  is  found  to 
be  the  only  means  of  relief  to  the  paroxysm.  Other 
remedies  are,  however,  employed  at  this  hospital, 
such  as  iodide  of  ether,  quinine,  amyl  nitrite ;  iodide 
of  potassium  given  up  to  grs.  clxxx.  daily,  has  been 
of  no  service ;  potassium  bromide  in  doses  of  grs. 
cxx.  daily,  has  brought  no  relief.  But  when  all  such 
efforts  are  useless,  as  occasionally  happens,  morphia 
affords  decided  benefit  ;  it  has  never  failed.  For 
relieving  the  cough  of  the  concurrent  bronchitis  the 
following  prescription  is  given  with  very  great  advan- 
age : 


104  SPASMODIC  ASTHMA — HAY   FEVER. 

9-     Tinct.  belladonnae    .         .         .     gtt.  xv. 

Sodii  carb.         .         .         .         .      grs.  x. 

Aquae  q.   s.  ' 

M.     Sig.  Dose. 

GERMAN  HOSPITAL. 

In  the  asthma  of  children,  depending  on  emphy- 
sema and  bronchitis,  Dr.  Jacobi  obtains  great 
improvement  by  the  administration  of  : 

I^.     Potass,  iodid.         .         .         .       grs.  iii-v. 
Aquae  q.s. 

M.     Sig.  Dose,  three  times  daily,  after  meals. 

Care  is  taken  that  the  drug  does  not  cause  any 
gastric  disturbance. 


BRONCHITIS. 


Definition. — Inflammation  of  the  membrane 
lining  the  bronchial  tubes,  distinguished  by  hoarse- 
ness, cough,  dypsncea,  heat  and  dryness,  followed  by 
mucous  or  muco-purulent  expectoration  ;  these  vary- 
ing in  intensity  according  to  the  severity  of  the 
inflammation,  and  the  extent  of  involvement  of  the 
smaller  tubes.  The  discharge  is  at  first  diminished 
in  quantity,  but  soon  becomes  abnormally  abundant 
and  altered  in  quality. 

BELLEVUE  HOSPITAL. 

Acute  Catarrhal  Bronchitis. — In  slight 
attacks,  considered  as  an  ordinary  cold.  Dr.  Alonzo 
Clark  advises  that  many  cases  may  be  left  alone. 
When  treatment  is  required  at  the  onset  of  the 
attack*  he  orders  the  patient  to  take  a  warm  bath  at 
night,  and  then  without  drying  to  wrap  in  blankets 
and  sweat.  Next  morning  friction  is  to  be  applied, 
especially  over  the  chest,  with  a  coarse  towel.  Where 
an  expectorant  is  needed,  he  almost  invariably  pre- 
scribes : 

^.     Syrup,  senegae  .  .  .  J  iii. 

Tinct.     opii  camphor.       .         .  3  ss. 

M.     Sig.     A  teaspoonful  every  three  hours. 

105 


I06  BRONCHITIS. 

If  this  amount  produces  nausea,  he  dilutes  it  with 
one-third  common  syrup.  In  other  instances  he 
gives 

]^.     Tinct.  benzoini  co.       .         .         .     gtt.  x. 

Sig.  Dose,  on  sugar  every  three  or  four  hours. 

When  active  fever  is  present,  the  so-called  influ- 
enza, Dr.  Clark  administers  diaphoretic  treatment 
with  tonics,  the  use  of  the  atomizer,  and  the  warm  or 
foot  bath.  An  easy  perspiration  is  thus  kept  up,  and 
if  there  is  much  weakness  the  patient  is  put  to  bed. 
A  moderate  amount  of  alcoholic  stimulant  is  also 
given.  By  this  means  the  fever  usually  passes  off  in 
four  or  five  days,  although  the  cough  may  last 
over. 

In  the  first  stages  of  acute  bronchitis  in  children. 
Dr.  J.  Lev\^is  Smith  prescribes  the  following,  with 
very  marked  benefit : 

5"     Tinct.  veratri  viridis         .         .         m.  xii. 
Syr.  scillae  co.  ...  3  ii- 

Syr.  balsam,  tolut.   ...  3  xiv. 

M.     Sig:  Ateaspoonful  every  two  or  three  hours. 

When  the  temperature  falls  and  the  moisture 
appears  on  the  skin,  under  the  above  influence,  its 
administration  is  stopped,  and  the  following  given : 

5-.     Ext.  cubeb.  fl.     .         .         .        m.  xl-3i. 
Syr.  simplic.         ...  3  iiss. 

M.     Sig.    A  teaspoonful  three  or  four  times  daily. 

In  the  primary  bronchitis  of  infants  of  one  year. 
Dr.  Smith  finds  the  following  combination  very 
serviceable  : 


BRONCHITIS.  107 

^.     Spts.  aether,  nitrosi  .         .         .      3  i- 

Syr.  ipecac.  .         .         .         .     3  ii- 

01.  ricini         .         .         .         .  .     3  ii- 

Syr.  tolutan.  ...  3  vii. 

M.     Sigi     A  teaspoonful  every  two  to  four  hours. 

At  the  invasion  of  mild  attacks,  with  coryza,  etc., 
Dr.  Loomis  gives  a  Dover  s  pozvder  and  warm  bath 
at  night,  followed  by  a  saline  purge  in  the  morning, 
or  in  children  by  a  dose  of  -castor  oil ;  the  patient 
remaining  in  the  house  for  one  or  two  days.  The  fol- 
lowing formula  for  Dover's  powder  is  much  used  at 
this  hospital : 

p.    Pulv.  opii  (12  per  cent.) 

Pulv.  ipecac  .  .  .         aa  pars  i. 

Sacchari  lactis     .  .         .      partes  viii. 

M. 
Should  these  measures  fail,  he  then  resorts  to  diu- 
retics and  diaphoretics.  In  severer  forms  of  the  dis- 
ease he  finds  counter-irritation  by  means  of  cups  or 
sinapisms  very  serviceable.  In  children  the  inhala- 
tion of  the  vapor  of  molasses  and  water  is  often  very 
beneficial.  Where  extension  to  the  smaller  bronchi 
or  a  chronic  form  is  impending,  he  administers 
quinine^  grs.  viii-x.  daily,  and  when  indicated,  as  in 
children,  cod  liver  oil. 

Capillary  Bronchitis.  —  Dr.  Clark's  treat- 
ment is  made  somewhat  energetic.  A  warm  bath  is 
administered,  and  the  oil-silk  jacket  applied,  inducing 
a  copious  and  early  diaphoresis.  Too  many  bed- 
clothes are  found   to  be  oppressive ;  this  should  be 


I08  BRONCHITIS. 

borne  in  mind.  Expectorants  he  considers  of  very- 
little  good.  In  addition  to  these  measures,  he  places 
the  patient  on  a  milk  diet  and  administers  tonics, 
iron  and  quinine. 

Dr.  Loomis  confines  the  patient  to  bed,  the  air 
of  the  room  being  moistened  with  steam ;  or  the 
steam  tent  is  used  with  excellent  service.  Dry  cups 
are  applied  to  the  chest,  followed  by  the  oil-silk 
jacket.     Internally  he  gives  : 

I^.     Ammon.  muriat. 

Potass,  chlorat.         .         .  aa  grs.  v-x. 

Sig.  Dose,  every  two  hours  to  adults. 

Expectorants  are  of  little  value.  To  relieve  the 
severe  bronchial  spasms,  hydrocyanic  acid  is  given 
with  benefit.  Opium  he  believes  does  harm  by  les- 
sening the  power  of  expectoration.  For  the  exhaus- 
tion which  is  usually  present,  stimulants  are  admin- 
istered. When  signs  of  deficient  aeration  of  the 
blood  appear,  oxygen  is  given  by  inhalation,  and  an 
emetic  is  administered  with  great  relief,  especially  in 
children.  Later  on,  when  the  heart's  action  becomes 
feeble  and  the  respiratory  movements  less  frequent, 
stimulants,  brandy  and  quinine,  are  freely  demanded. 
The  diet  is  made  nutritious  throughout,  consisting 
chiefly  of  milk  and  eggs. 

In  urgent  cases  the  treatment  at  this  hospital  is 
somewhat  as  follows :  Where  there  is  a  condition  of 
severe  dyspnoea,  prostration,  more  or  less  cyanosis, 
respiration  rapid  and  superficial,  pulse  weak,  and  the 
first  sound  of   the  heart   faint,  dry  cups,  from  thirty 


BRONCHITIS.  109 

to  fifty  in  number,  are  applied  to  the  chest,  and  the 
following  given : 

5..     Tinct.  digitalis         .         .         .         gtt.  x. 
Spts.  frumenti         .         .         .  5  ss. 

M.     Sig.     Dose,  every  two  hours. 

If  the  cyanosis  increases,  the  respiration  grows 
short  and  very  rapid,  pulse  failing  and  the  first  heart- 
sound  lost,  with  all  evidences  of  impending  suffoca- 
tion, the  patient  is  cupped  repeatedly  over  the  chest 
and  kidneys,  and  infiis.  digitalis^  §  ss.  every  hour, 
administered,  together  with  whiskey y  ^  ss.  every  half- 
hour.  Poultices  are  also  applied  over  the  chest  and 
renewed  every  hour.  If  this  fails  to  bring  up  the 
heart,  grs.  v  of  ammonium  carbonate,  are  given  every 
half-hour.  By  these  efforts,  repeated  and  kept  up  as 
demanded,  success  may  follow ;  or  in  spite  of  all 
exertions  the  case  may  gradually  become  worse  and 
worse. 

Chronic  Bronchitis.  —  Dr.  Austin  Flint 
places  the  patient  on  tonics ,  cod  liver  oil,  etc.,  and 
the  observance  of  good  hygiene.  For  the  dyspnoea, 
quebracho  is  employed  with  marked  benefit,  given  in 
doses  of  m.  xx-xxx.  of  the  fluid  extract. 

Dr.  Alonzo  Clark  gives  the  following  with 
good  effect  in  the  slight  attacks  or  exacerbations 
which  frequently  recur  from  exposure : 

!p.     Mist,  guaiaci         .         .         .  3i-5ss. 

Tinct.  balsam,  tolut.  .         gtt.  vi-x. 

M.     Sig.  Dose,  every  three  hours. 

Dr.    Loomis'    treatment    depends    in    a    great 


I  lO  BRONCHITIS. 

measure  upon  the  associate  condition;  <f.^.,  heart 
disease,  emphysema,  rheumatism,  etc.  These  are  to 
receive  special  medication.  For  the  paroxysms  of 
cough,  opium  or  hydrocyanic  acid  are  found  very 
serviceable.  The  following  formula  is  used  at  this 
hospital : 

5.     Potass,  cyanidi 

Morphiae  sulph.  .         aa  grs.  xvi. 

Syrup,  tolut.  .         .         .  3  xvi. 

M.     Dose  :  A  teaspoonful. 

If  the  spasms  are  very  severe,  the  inhalation  of  a 
few  drops  of  ctJicr  or  cJilorofonn  often  give  relief. 
For  an  expectorant,  senega^  camphor^  or  tincture  of 
benzoin  combined  with  potassium  or  sodium  carbon- 
ate are  very  useful.  Counter  irritation  is  also  resorted 
to  at  times  with  much  benefit.  The  inhalation  of 
steam,  or  of  the  vapor  of  iodine,  often  relieves  the 
abundant  secretions.  When  the  power  of  expectora- 
tion is  greatly  weakened,  an  emetic  may  be  given 
with  good  result.  In  addition  to  tht^e  means  of  treat- 
ment, Dr.  Loomis  instructs  the  patient  to  avoid 
all  exposure  to  changes  of  the  weather,  and  if  pos- 
sible to  remove  to  a  warm,  dry  climate.  Where 
emaciation  is  marked,  a  sea-voyage  is  advised  with 
benefit.  The  diet  should  be  nutritious,  combined  with 
moderate  stimulation  ;  with  this  he  also  prescribes 
tonics,  iron  and  quinine^  especially  if  an  anaemic  con- 
dition is  present,  and  means  to  improve  the  diges- 
tion. 

Dr.  J.  Levv^is  Smith  employs  the  following  with 
advantage  in  children,  where  there  is  also  anaemia : 


BRONCHITIS.  Ill 

'^.    Ferri  et  ammon.  citrat. 

Ammonii   carbon.  .         aa  grs.  xxxii. 

Syrupi 

Aquae  anisi  .         .         .         .         aa  fl.  5  ii. 
M.     Dose,  a  teaspoonful. 

With  heart  disease  present,  he  frequently  pre- 
scribes : 

5.   Tinct.  digitalis       .         .         .         gtt.  xvi 
Ammon.  chloridi  .         .         .         grs.  xvi 
Syrup,  tolutan.       .         .         .         . 
Aquae     ...... 

M.     Dose,  a  teaspoonful. 

In  those  cases  of  prolonged  bronchitis  in  children, 
especially  if  associated  with  heart  trouble,  Dr. 
Jacobi  first  insists,  as  far  as  possible,  on  absolute 
rest.  He  directs  that  the  child  be  kept  in  a  mild, 
equable  temperature,  and  subjected  to  the  occasional 
use  of  steam  inhalations.  For  medicinal  treatment 
he  makes  use  of  the  following  with  benefit : 

p.    Morphiae  sulph.     .         .         .         .      gr.  i. 

Ext.  digitalis  fl.     ,         .         .         gtt.  xvi. 

Aquae    .         .         .         .         .         .        §  ii« 

M.     Sig.  A  teaspoonful  four  times  a  day. 

He  also  employs  the  iodides  to  promote  absorption 
of  the  exudation.  Of  these  he  prefers  the  iron  and 
the  soda  salts  ;  but  so  long  as  fever  of  an  inflamma- 
tory or  catarrhal  character  is  present,  he  would  not 
use  the  iodide  of  iron.  Dr.  Jacobi  not  infrequently 
finds  an  elongated  uvula  causing  excitation  or  tick- 
ling of  the  pharynx.     This  sets  up  a  constant  irrita- 


112  BRONCHITIS. 

tion  which  is  apt  to  give  rise  to  a  pharyngeal  cough, 
extending  downward  to  the  bronchi.  In  these  cases 
he  advises  the  removal  of  such  an  elongated  uvula  at 
the  earliest  moment.  It  should  not  be  done,  how- 
ever, when  diphtheria  is  prevailing. 

The  following  is  Dr.  E.  G.  Janeway's  prescrip- 
tion, and  is  considered  very  serviceable,  being  exten- 
sively used  at  this  hospital : 

]^.    Potass,  iodidi       ....  3  iii- 

Tinct.  tolutan.    .         .         ...  3  i- 

Ext.  pruni  virg.  fl.       .         .         .  3  i. 

Syrupi          .....  §  i. 

Spts.  aether,  co.            .         -         .  §  ii. 

Aquae          .         .         .          .         .  3  i. 

M.    Dose  :  A  teaspoonful. 

Plastic  Bronchitis. — Dr.  Clark  employs  inha- 
lations of  steam,  not  too  hot,  thrown  full  in  the  face 
and  breathed.  For  this  purpose  he  prefers  the  steam 
of  lime  zuaterdiS  more  efficacious  than  ordinary  steam, 
in  this  form  of  bronchitis.  The  system  is  also  to  be 
supported  by  a  good,  nutritious  diet  and  the  admin- 
istration of  tonics,  iron  and  cod  liver  oil. 

Dr.  Loomis'  treatment  is  in  every  respect  similar 
to  the  above. 

Fetid  Bronchitis. — In  addition  to  his  usual 
means  of  medication,  etc..  Dr.  Clark  employs  some 
antiseptic  to  destroy  the  odor  and  to  deodorize  the 
room.  Very  often  a  sponge  dipped  in  carbolic  acid 
is  quite  serviceable  for  this  purpose. 


BRONCHITIS.  113 

NEW  YORK  HOSPITAL. 

Acute  Catarrhal  Bronchitis. — In  the  severer 
forms  of  this  disease  where  the  smaller  bronchi  are 
involved,  and  there  is  great  dyspncea  with  evidence 
of  collapsed  lung,  alcoholic  stimulants  are  given 
immediately,  with  carbonate  of  ammonium,  and 
opium  to  stimulate  the  heart  and  lessen  the"dyspnoea. 
In  regard  to  the  use  of  opmni  in  these  cases,  Dr.  W. 
H.  Draper  considers  it  a  most  efficient  remedy. 
He  advises  a  cautious  administration,  however,  in 
sufficient  quantity  to  derive  benefit  from  its  action, 
namely :  as  a  cardiac  stimulant  arousing  the  weak- 
ened circulation,  relaxing  the  spasmodic  contraction 
of  the  bronchial  tubes  and  allowing  the  free  ingress 
of  air,  and  controlling  the  dyspnoea.  The  following 
case  will  exemplify : 

Four  weeks  previous  to  admission  the  patient,  a 
female  set.  40,  began  to  suffer  from  cough  with  pro- 
fuse expectoration.  Two  weeks  later  there  was 
urgent  dyspnoea.  When  admitted,  her  chart  showed 
respiration  50,  temperature  100.6,  and  pulse  96.  Per- 
cussion gave  fair,  but  modified,  resonance  both  in 
front  and  posteriorly.  Auscultation  in  some  places 
was  negative ;  in  others  loud,  coarse  rales,  sonorous 
and  moist,  were  heard.  Expectoration  muco-puru- 
lent.  Prostration  was  extreme  and  the  patient  was 
apparently  dying  from  dyspnoea.  Her  breathing 
was  exceedingly  labored,  countenance  anxious,  skin 
dusky,  and  the  pulse  very  feeble.  Stimulants  were 
at  once  administered  freely.  Ammonium-  carbonate 
8 


1 14  Bronchitis. 

was  given  but  not  retained.  Alcohol  and  opium 
were  then  ordered.  Liq.  niorph.  sulph.  {J^Iagendie), 
m.  V.  were  given  hypodermically,  and  shortly  after- 
ward m.  X.  more  of  the  same  solution  were  injected. 
Under  the  influence  of  this  treatment  she  began 
steadily  to  improve,  and  on  the  following  day  was 
quite  comfortable,  although  seemingly  moribund  on 
admission.  Within  forty-eight  hours  her  breathing 
was  much  less  labored,  respiration  down  to  30,  pulse 
fair,  and  general  condition  good. 

The  following,  from  this  hospital,  is  often  very 
serviceable  in  the  acute  as  well  as  in  the  more  chronic 
form  of  bronchitis  : 

9--    Potass,  iodid.      ....  3  iii. 

Spts.   aether,  co.          .          .          .  J  i- 

Syr.  pruni  virg.           ...  5  iii. 

M.    Sig.  A  teaspoonful. 

Capillary  Bronchitis. — Prompt  and  energetic 
measures  are  immediately  adopted.  Dry  cups  are 
applied  to  the  chest,  and  brandy  and  ammonium  car- 
bonate given.  The  following  combination  is  fre- 
quently used  at  this  hospital : 

9-    Ammon.  muriat. 

Potass,  chlorat,         .         .         .         aa  3  i- 
Ext.  glycyrrh.  ...  3  ss. 

Aquae  cinnam.         ...  3  iv. 

M.    Dose  :  A  teaspoonful. 

To  allay  the  bronchial  spasms  hydrocyanic  acid  is 
often  very  beneficial.  The  following  is  the  formula 
employed  at  this  hospital : 


BRONCHITIS. 


115 


9.    Potassi  cyanidi  .         .      '   .         grs.  11. 

Syrup,  tolutan.  .         .         . 

Liq.  morph.  sulph.  (U.  S.  P.)      .       aa§i. 
M.    Dose.    A  teaspoonful. 

The  above  is  also  used  with  advantage  in  chronic 
bronchitis. 


ST.  LUKE'S  HOSPITAL. 


simple 


3ii. 

31. 

§  iii. 

5  ss. 

S  ss. 

3iss. 


Acute     Catarrhal    Bronchitis.— In 
bronchitis,  Dr.  J.  R.  Leaming  prescribes : 
]^.    Ammon.  chlorid. 

Potass,  chlorat. 

Aquae  cinnam. 

Syrup,  senegae 

Spts.  aether  nitros. 

Ext.  glycyrrh. 
M.    Dose.  A  tablespoonful  every  two  hours. 

This  he  finds  of  excellent  service,  adding  tartar 
emetic,  belladonna,  aconite,  or  tincture  of  iron  when 
desired,  according  to  indications. 

Chronic  Bronchitis. — Dr.  A.  H.  Smith  has 
repeatedly  made  use  of  quebracho  to  relieve  the  par- 
oxysms of  dyspnoea,  and  found  it  very  effective  in 
almost  every  instance ;  either  with  or  without  em- 
physema present.  He  uses  \\i^  fluid  extract  in  doses 
of  in.  XXX— xl.^  three  times  daily. 

Dr.  Beverly  Robinson  places  much  reliance  on 
the  following  prescription,  which  is  a  favorite  with 
him : 

9.    Ammonii    carbon.  .         .         grs.  x. 

Syr.  ipecac.        .       .  ,         .3  iss. 


Il6  BRONCHITIS. 

Tinct.    opii   camph.         .         .  3  i. 

Syr.  pruni  virg.        .  ,  .  3  ss. 

Aquae  q.  s.  ad  .  .  .  J  "• 

M.    Dose.  A  teaspoonful  to  a  tablespoonful. 

MT.  SINAI    HOSPITAL. 

Chronic  Bronchitis. — In  children,  when  there 
is  present  a  condition  of  peribronchitis  with  catarrh, 
and  more  or  less  fever.  Dr.  Jacobi  confines  the  pa- 
tient to  bed  for  three  or  four  days,  and  administers 
quinine,  grs.  viii.  daily,  taken  during  the  forenoon.  If 
the  cough  is  severe,  he  gives  pulv.  Dovcri.  grs.  v.  at 
night. 

With  this  he  combines  warm  drinks  to  induce 
diaphoresis.  After  the  fever  has  subsided,  to  reduce 
the  amount  of  exudation,  and  to  assist  in  the  ab- 
sorption of  that  already  present,  he  prescribes : 

^.     Potass,  iodidi  .  .  grs.  iii-v. 

Aquae,  q.  s. 

Sig.  Dose,  three  times  daily,  some  time  after 
meals. 

Care  is  taken  that  the  drug  does  not  disarrange 
the  stomach.  The  nutrition  is  to  be  sustained  by 
good  diet,  etc. 

For  the  attacks  of  bronchitis  occurring  in  cases  of 
asthma,  the  following  is  used  with  service  in  reliev- 
ing the  cough : 

^.    Tinct.  belladonnae  .  .         gtt.  xv. 

Sodii  carb.  =         .  .  grs.  x. 

Aquae  q.  s. 

M.    Sig.  Dose. 


BRONCHITIS.  1 17 

CHARITY  HOSPITAL. 

Capillary  Bronchitis. — For  the  high  tempera- 
ture, Dr.  Beverly  Robinson  gives  quinine  in  large 
doses.  In  cases  occurring  secondary  to  cardiac  dis- 
ease, when  the  temperature  is  only  moderate  in  de- 
gree, and  the  heart  becomes  weak  and  irregular,  the 
respiration  panting  and  laborious,  and  the  general 
symptoms  alarming,  he  stops  the  quinine,  and  gives 
large  doses  of  digitalis  with  marked  benefit.  If  seen 
from  the  commencement,  he  begins  with  tinct.  of  digi- 
talis, gtt.  v-xv.  tJwee  or  four  times  daily;  or  3  i-iii. 
of  the  infusion.  If  any  great  degree  of  prostration 
becomes  manifest,  he  combines  the  digitalis  with 
small  doses  of  strychnia.  If,  however,  the  patient 
is  not  seen  until  the  later  stages,  when  pulmonary 
obstruction  is  intense,  Dr.  ROBINSON  does  not  hesi- 
tate to  administer  3  i  doses  of  tinct.  digitalis  every 
four  hours,  until  the  anxiety,  praecordial  oppression, 
and  the  very  pronounced  dyspnoea  have  partially 
subsided.  The  following  hydrocyanic  acid  mixture 
is   very  much  used  at  this  hospital : 

^.    Potass,  cyanidi  .  .  .        grs.  ii. 

Vini  antimonii  .         .         «  3  ii- 

Syr.  tolutan. 
Mucil.  acaciae 
Aquae  q.  s.  ad 

M.     Dose.  A  teaspoonful. 

This   will    also   be    found    of    marked    service    in 
chronic  bronchitis. 


aa  3  ss. 
\  ii. 


EMPHYSEMA. 


Definition. — {a)  Vesicular. — Increase  of  air  in  the 
air-cells  of  the  lungs,  producing  excessive  dilatation, 
followed  by  obliteration  of  their  blood  vessels,  degen- 
eration and  ultimate  rupture  or  their  walls,  establish- 
ing a  communication  with  one  another,  and  the  final 
union  of  many  into  one  or  more  large  and  irregularly 
shaped  vesicles  or  sacs,  {b)  Interlobular. — Extravasa- 
tion of  air  into  the  interlobular  areolar  texture  of 
the  lung,  consequent  upon  laceration  of  its  sub- 
stance from  concussion  or  other  violence. 

BELLEVUE  HOSPITAL. 

For  the  bronchitis,  which  is  usually  the  objective 
point  in  the  treatment,  besides  certain  paUiative 
measures,  Dr.  AUSTIN  Flint  uses  the  iodide  of 
potassium,  ammonium  or  potassium  chloride,  and  the 
balsamic  remedies.  By  this  means  he  accomplishes 
a  great  deal  of  good  in  these  cases.  The  following 
is  often  prescribed  at  this  hospital : 

5.     Potass,  iodidi  ....      3  iii- 

Ammon.  carbon grs.  1. 

Syrup,  pruni  virg. 

Spts.  eether.  CO.      .         .         .  aa^iss. 

M.    Dose.  A  teaspoonful. 

118 


EMPHYSEMA.  II9 

For  the  dyspnoea,  he  has  found  the  fluid  extract 
of  quebracho  often  of  great  service.  In  many  cases 
with  bronchitis  and  asthma,  where  this  symptom  is 
constant  and  increasing,  m.xxx,  every  three  hours, 
has  afforded  greatest  benefit,  the  dyspnoea  disap- 
pearing and  the  appetite  and  strength  improving  in  a 
marked  degree.  Dr.  FLINT  also  places  the  patient 
upon  tonics,  cod  liver  oil,  etc.,  combined  with  good 
hygienic  measures.  Thus  a  further  increase  of  the 
emphysema  may  be  prevented,  but  it  can  hardly  be 
expected  to  cure  the  bronchitis.  A  change  of  occu- 
pation is  also  advised. 

When  spasmodic  asthma  is  a  prominent  recurrent 
symptom,  in  addition  to  a  general  tonic  plan  of  treat- 
ment the  following  is  employed  with  marked  benefit : 

9.    Potass,  iodidi  .         .         .  .         .      3  ii- 

Spts.  ^ther.  co.        .         .  .         .     §  ss. 

,  Syr.  pruni  virg.         .  .         .  .     5  iv. 

M.     Sig.  A  teaspoonful  four  times  daily. 

For  emphysema  due  to  the  rupture  of  an  asthma 
from  concussion  or  pressure.  Dr.  Alonzo  Clark 
advises  that  very  little  can  be  done.  If  left  to  itself 
the  rupture  will  heal  and  the  air  be  taken  up  by 
absorption.  In  ordinary  emphysema  his  treatment 
is  directed  to  the  asthma  or  bronchitis  attending  it. 
If  the  daily  occupation  of  the  patient  calls  for  forced 
action  of  the  lungs,  e.  g.,  wind  musicians,  this  should 
be  given  up.  When  the  accompanying  bronchitis 
has  gained  a  chronic  condition,  he  advises  removal 
to  another  climate ;  whether  colder  or  warmer  de- 
pends entirely  upon  the  patient,  in  which  he  expe- 


120  EMPHYSEMA. 

riences  the  most  benefit,  but  in  either  case  he  would 
insist  upon  the  cHmate  being  a  dry  one.  If  circum- 
stances do  not  permit  of  this  change,  Dr.  Clark 
then  administers  a  general  tonic  plan  of  treatment 
combined  with  the  observance  of  good  hygiene.  He 
also  gives  strychni(E  siilpJi.^  gr.  ^,  four  times  daily,  in 
conjunction  with  cod-  liver  oil.  When  heart  disease 
is  also  present,  and  the  attacks  are  marked  with 
severe  dyspnoea,  pain,  cough,  and  cardiac  disturb- 
ance, these  symptoms  becoming  aggravated  at  night 
with  possibly  night  sweats.  Dr.  Clark  makes  use  of 
the  following  with  good  effect  in  these  cases : 

^.    Potassii  iodid.        ....    grs.  x. 
Tinct.  digitalis       ....    gtt.  x. 

M.     Sig,     Dose,  three  times  daily. 

Dr.  Loomis  aims  chiefly  to  build  up  the  defective 
nutrition.  The  diet  is  made  rich  and  nutritious, 
chiefly  animal,  and  everything  producing  flatulence 
carefully  avoided.  Moderate  out-door  exercise  may 
be  taken,  but  exposure  to  cold  or  anything  exciting 
dyspnoea  must  be  guarded  against.  A  change  of 
residence  is  also  advised  to  that  locality  which  proves 
most  agreeable  to  the  patient.  For  internal  admin- 
istration he  gives  iron  daily  for  a  considerable  period, 
combined  with  opium  in  small  doses.  When  dyspeptic 
symptoms  are  prominent  he  makes  use  of  the  viin- 
cral  acids  and  vegetable  tonics,  together  with  cod  liver 
oil  if  there  is  much  emaciation.  For  the  bronchitis, 
which  is  often   very  distressing,  Dr.  Loomis  gives: 

5.    Potass,  iodidi  ....    grs.  x-xx. 

Sig.     Dose,  three  times  a  day. 


EMPHYSEMA.  121 

This  he  continues  for  some  time  and  often  with 
marked  benefit. 

PRESBYTERIAN  HOSPITAL. 

For  the   dyspnoea,  ext.  quebracho  fl.^   in  doses  of 
fn.xx-xL,  is  often  used  with  much  relief. 

NEW  YORK  HOSPITAL. 

.  Dr.  W.  H.  Draper  directs  attention  to  the  fact 
that  emphysema  is  often  developed  in  patients  with 
acquired,  or  hereditary,  gout  or  chronic  rheumatism ; 
and  that  with  trie  asthma  present  the  gout  is  almost 
sure  to  show  itself.  He  therefore  considers  the 
recognition  of  this  state,  which  is  so  frequently  over- 
looked, an  important  feature  in  the  treatment,  since 
it  calls  for  dietetic  and  hygienic  regulations  which 
improve  the  condition  of  the  patient.  He  recom- 
mends a  change  of  climate,  where  the  patient  can  be 
out  of  doors  much  of  the  time  and  enjoy  plenty  of 
fresh  air.  This  is  also  demanded  by  the  gouty  dia- 
thesis. He  also  prescribes  a  simple  diet,  not  to  any 
great  extent  carbonaceous,  and  without  the  fermented 
liquors ;  advising  the  use  of  animal  and  vegetable 
foods  to  the  exclusion  of  wine,  beer  and  cider.  For 
medicinal  treatment  in  these  cases.  Dr.  Draper 
objects  to  the  expectorants,  lobelia,  ipecac,  opium  ; 
or  the  syrups  which  act  specifically  on  the  mucous 
membrane.  He  makes  use  of  the  rheumatic  treat- 
ment, giving  the  citrate  of  potassium  or  sodium,  or 
any  of  the  common  alkalies,  to  be  taken  on  an  empty 


122  EMPHYSEMA. 

stomach.     The  following,  from  this  hospital,  is  a  very 
agreeable  form  of  administration  : 

5-    Potassii.  citrat.  .         .         .  5  iss. 

Syrup,  limonis 
Aquae.     .         .         .  .  .       aa  3  iii. 

M. 

When  the  nervous  element  of  the  disease  is  prom- 
inent, he  gives  potassium  iodide  and  tonics,  such  as 
iron,  cod  liver  oil,  etc.  If  the  patient  has  been  enjoy- 
ing a  life  of  luxury  with  abundance  of  wines  and 
high  living,  this  must  all  be  put  aside  and  a  radical 
change  brought  about  in  the  state  of  things  which 
has  caused  the  disease. 

ROOSEVELT    HOSPITAL. 

For  the  bronchitis  which,  as  a  rule,  requires  most 
of  the  treatment.  Dr.  Francis  Delafield  uses  a 
mixture  of  iodide  of  potassium,  wine  of  ipecac,  and 
Hoffman's  amodyne,  combined  with  the  administra- 
tion of  iron  and  quinine  ;  also  cod  liver  oil,  when 
indicated,  of  which  the  following  preparation  is  used 
at  this  hospital : 

^.    Olei  morrhuae     .         .         .         .  3ii- 

Spts.  lavandulae  co. 

Vini  gallici         .         .  .         .      aa  3  i- 

M.    Sig.   Dose. 

When,  however,  all  these  measures  fail,  he  often 
finds  that  sulpJmric  acid  affords  great  relief.  This 
he  administers  in  rather  larger  doses  than  ordinary, 
giving  : 


EMPHYSEMA.  1 23 

5-     Acid,  sulphur,  aromat.        .     gtt.  xv-xx. 

Sig.  Dose,  three  or  four  times  daily, 
and  stopping  all  other  remedies  except  the  oil, 
which  is  continued  with  advantage.  In  order  to 
ascertain  whether  the  acid  is  to  be  of  service  in  any 
case,  he  directs  that  it  be  tried  for  at  least  three 
weeks.  Where  the  bronchitis  is  very  slight  or 
absent,  as  occasionally  happens,  and  the  patient  suf- 
fers from  dyspnoea  and  cough.  Dr.  Delafield  sim- 
ply attends  to  the  general  health,  and  avoiding  those 
remedies  usually  employed  in  other  instances  he 
makes  use  of  cod  liver  oil,  iron  and  quinine,  con- 
tinued steadily  for  some  time.  He  also  employs 
iron  and  arsenic  with  benefit  in  these  cases.  The 
following  pill  is  an  excellent  combination,  and  very 
much  used  at  this  hospital : 

9-.    Acid,  arsenios.        ...  gr.   l-^. 

Ferri   redacti  .  .  .         gr.  i-ii. 

Quinise  sulph.         .         .         .         gr.  i-ii. 
M.    ft.  pil.  No  i. 
Sig.  To  be  taken  three  times  daily. 


PULMONARY    HEMORRHAGE- 
CON  GESTION-APOPLEXY. 


Definition. — A  discharge  of  blood  from  the 
lungs  by  expectoration  (haemoptysis)  ;  resulting  from 
hyperaemia  of  the  capillary  vessels  (congestion),  or 
from  direct  extravasation  into  the  air-cells  and  ter- 
minal bronchi  ;  in  the  latter  instance  the  blood  tends 
also  to  accumulate  in  the  tissues  (apoplexy). 

NEW  YORK  HOSPITAL. 

Dr.  W.  H.  Draper  calls  attention  to  the  import- 
ance of  not  pushing  the  treatment  too  far  at  the 
onset,  particularly  in  cases  of  free  haemorrhage. 
Where  there  is  active  congestion  with  severe 
dyspnoea,  dry  cupping  is  very  beneficial ;  or  some- 
times when  associated  with  oedema,  diuretics  and 
cathartics  are  used  with  advantage.  In  cases  of 
pulmonary  apoplexy,  stimulants  are  administered, 
absolute  rest  enforced,  and  the  recumbent  position 
in  bed  maintained.  In  severe  haemoptysis,  especially 
if  causing  cerebral  anaemia,  the  patient  is  immediately 
put  to  bed,  kept  perfectly  quiet  and  not  allowed  to 
talk.  To  relieve  the  bleeding,  cxt,  ergot,  fl.,  vi.x-xx. 
are  given  at  once,  and  repeated  as  indicated.  Liquor 
viorph.  sulph.  {Magatdic),  ut.x.,  are  also  adminis- 
tered hypodermically.     This  stimulates  the  heart  and 

124 


PULMONARY   H/EMORRHAGE,    ETC.  125 

composes  the  mind,  relieving  the  apprehension  which 
always  accompanies  loss  of  blood  from  the  lungs. 
Gallic  acid  is  also  given.  Dr.  Draper,  however, 
believes  that  the  controlling  effect  of  ergot  and  the 
astringents  is  more  marked  in  ordinary  haemorrhage 
due  to  congestion.  If  the  source  of  the  haemorrhage 
is  ascertained,  he  d^i^^Xi^s  poultices  of  ice  to  the  chest. 
Complete  rest  should  always  be  insisted  on,  and 
examinations  to  ascertain  the  source  of  the  blood 
should  be 'exercised  with  the  utmost  care,  and  never 
made  until  the  immediate  effects  are  recovered  from. 
The  following  solution  of  ergot  is  used  for  hypoder- 
mic administration  : 

5.    Ext.  ergot.  (Squibb's)     .         .  pars  i. 

Aquae  destil.  carbol.        .  .         part.  v. 

M. 

BELLEVUE  HOSPITAL. 

Dr.  Alonzo  Clark  believes  the  fluid  extract  of 
ergot  to  be  as  efficacious  as  anything  for  internal  use. 
But  he  places  still  greater  reliance  on  tying  off  some 
of  the  vessels  and  holding  the  blood  in  the  veins  for 
a  few  minutes,  thus  relieving  the  lungs.  A  bandage 
placed  about  the  arm  will  suffice,  the  blood  being 
thus  permitted  to  accumulate  in  the  veins.  He 
advises  caution,  however,  about  allowing  the  blood 
to  remain  tied  off  for  any  great  length  of  time  in  one 
part.  He  prefers  to  liberate  the  vessels  in  one  arm 
after  the  ligature  has  been  applied  for  a  period  of 
five  minutes,  and,  if  necessary,  tie  up  the  other  arm 
or  leg.     Dr.  Clark  has  never  found  this  method  to 


126        PULMONARY  HEMORRHAGE. 

fail  in  a  single  instance.  Where  the  haemorrhage  is 
moderate  he  finds  that  dry  cupping  will  serve  this 
purpose,  a  dozen  being  applied.  For  internal  admin- 
'ctration  the  following  is  often  used  at  this  hospital : 

]^.     Ext.  ergot,  fl.  ...  §  iv. 

Ext.  ipecac,  fl. 
Tinct.  opii  deodor.  .         .  aa  3  iv. 

M.    Sig.   A  teaspoonful  thrice  daily. 

Or: 

5.     Ext.  ergot,  fl.      .  .         .         .  J  "•  -^ 

Ext.  ipecac,  fl. 

Tinct.  opii  deodor.      .  .  .     aa3iv. 

Syrup,   simp.       .  .  .  .  3  ii. 

M.    Sig.   A  teaspoonful  three  times  daily. 

Dr.  Loomis  advises  rest  in  bed  with  absolute 
quiet,  avoiding  even  the  slightest  movements.  He 
has  very  little  faith  in  styptics  or  astringents,  especi- 
ally in  free  haemorrhage.  If  cough  exists  aggravat- 
ing the  bleeding,  opium  is  given  in  full  doses.  In 
extreme  cases  ice-bags  are  applied  to  the  chest,  but 
this  measure  must  be  resorted  to  with  care.  Where 
congestion  is  present  dry  cupping  is  employed  with 
much  benefit  ;  or,  when  in  his  judgment  indicated, 
blood  is  abstracted.  Ice  is  also  given  in  small  pieces, 
with  an  abundant  supply  of  cool  drinks.  If  a  recur- 
rence of  the  haemorrhage  is  apprehended,  everything 
provoking  such  a  tendency  is  guarded  against,  and 
the  strength  of  the  patient  supported  by  tonics,  iron, 
and  a  nutritious  diet.  Where  the  congestion  is 
dependent  on  feeble  cardiac  action,  stimulants  are 
used ;  if  the  opposite  condition  exists, 


CONGESTION — APOPLEXY.  12/ 

]^.    Tinct.  aconiti  rad.  (Fleming's)      gtt.  ii-iii. 

Sig.  Dose,  every  three  or  four  hours. 
may  be  given.  In  cases  of  pulmonary  apoplexy 
with  heart  disease,  stimulants  are  given  together 
with  digitalis.  Counter-irritation  by  means  of 
sinapisms  and  dry  cups  is  found  very  serviceable. 
When  associated  with  blood-poisoning,  sustaining 
measures  are  also  employed  and  stimulants,  iron  and 
quinine  freely  administered. 

CHARITY  HOSPITAL. 

In  moderate  haemorrhage,  Dr.  Beverly  ROBIN- 
SON 2cy^i^X\^s  fly-blisters  to  relieve  the  local  congestion. 
He  also  employs  ergot  with  excellent  results.  If 
the  bleeding  is  slight,  small  doses  are  usually  suffi- 
cient;  but  in  abundant  \\.'^m.oxx\\2i^^^  fluid  extract  oj 
ergot  in  doses  of  3  i-  is  administered  frequently,  and 
the  patient  given  small  pieces  of  cracked  ice  to  suck 
and  swallow.  This  plan  he  finds  very  successful. 
He  also  advises  abstinence  from  all  stimulants,  with 
the  observance  of  regular  habits,  restraint  from  over 
muscular  exertion,  plenty  of  open  air  and  good, 
nutritious  food. 

For  hypodermic  administration  the  following  is 
used  at  this  hospital : 

9-     Ergotini        ....     grs.  xxxvi. 
Glycerinae     .... 
Aquae  .         .         .         .     aa  m.  cviii. 

M. 

Dr.  J.  W.  Howe  has  practiced  transfusion,  both 
of  milk  and  of  blood,  in  some  cases  with  great  benefit. 


PULMONARY  CEDEMA. 


Definition. — Infiltration  of  serum  into  the  areo- 
lar tissue  of  the  lungs,  marked  by  increasing  dyspncea, 
cyanosis,  and  more  or  less  cough  with  watery  expec- 
toration. 

BELLEVUE    HOSPITAL. 

Dr.  Loomis  advises  that  dry  cups  be  applied  repeat- 
edly over  the  chest,  and  diuretics  given  combined, 
at  times,  with  hydragogues  and  diaphoretics.  In 
strong  and  robust  patients  bleeding  is  resorted  to 
very  efficiently.  Where  there  is  much  exhaustion 
with  feeble  heart  action,  stimulants  are  administered 
together  with  digitalis. 

As  a  rule,  at  this  hospital,  dry  cups  to  the  number 
of  50  to    150  are  applied   and   digitalis  ordered,  as 
follows : 
•    5"     Tinct.  digitalis.         .         .         .      gtt.  xx. 

Sig.  Dose,  every  two  or  three  hours, 
together  with  rt;;;/;;2d?«/?/;;/  carbonate grs.  v-x.,  at   cor- 
responding intervals.     Whiskey  is  also  given  in  doses 
of  §  ss.,  hypodermically  or  by  the  mouth.   These  are 
repeated  as  necessary. 

Sometimes  the  hot-pack  is  used.  Or  in  other  cases 
with  full  and  sthenic  pulse,  blood  is  drawn  to  5  x-xii, 

128 


PULMONARY   OEDEMA.  I29 

with  marked  effect.  In  strong  and  robust  patients 
with  good  pulse,  jaborandi^  in  doses  of  3  h  is  often 
used  with  decided  benefit ;  or: 

'^.     Ext.  jaborandi  fl.         .         .         m.  x-xv. 
Aquae         .  .         .  .         .         q.  s. 

M.     Sig.  Dose,  every  one  or  two  hours. 

Sometimes  pilocarpine  is  preferred,  in  doses  of  gr. 
i-iss.  It  is  found,  however,  that  pilocarpine  produces 
greater  depression  of  the  heart  than  jaborandi. 

Dr.  Austin  Flint  finds  dry  cupping  very  bene- 
ficial in  ordinary  cases.  But  in  sudden  attacks  of 
pulmonary  oedema  existing  in  a  degree  sufficient  to 
cause  much  obstruction  to  the  respiration,  show- 
ing a  condition  of  great  dyspnoea  and  cyanosis  with 
tense  and  full  pulse,  other  means  of  depletion  being 
too  slow  in  action.  Dr.  Flint  resorts  to  immediate 
venesection,  bleeding  to  Jx-xii.  This  is  usually  fol- 
lowed by  almost  instant  alleviation  of  the  symptoms, 
and  life  not  unfrequently  saved  by  this  prompt  mea- 
sure. The  dyspnoea  which  remains  he  treats  by 
inJialation  of  oxygen. 

NEW  YORK   HOSPITAL. 

Dr.  W.  H.  Draper  applies  dry  cups  with  great 
advantage  ;  the  extremities  are  kept  warm  and  stimu- 
lants ordered  as  follows  : 

9.     Spts.  vini  gall.       .         .         .         .         ^i- 
Tinct.  digitalis       ....  gtt.  x. 
Sig.  Dose,  every  two  hours. 

Ammonium  carbonate    is  also  given.     Sometimes 


130  PULMONARY   CEDEMA, 

turpentine  stupes  zx^  employed;  or,  in  other  instances, 
diuretics,  diaphoretics  and  cathartics  are  used  very 
serviceably.  Inhalation  of  oxygen  often  affords  the 
patient  much  relief  to  the  breathing.  In  certain  cases 
he  resorts  to  the  careful  administration  of  morphia 
with  excellent  effect,  giving  liquor  viorpJiicE  sulpJi. 
{Magendie),  gtt.  iv-vi.^  and  repeating  the  dose  every 
two  or  three  hours,  if  necessary.  Or  morphia  com- 
bined with  digitalis  is  used.  But  he  advises  that 
the  dose  of  morphia  as  a  heart  tonic  must  be  small. 

PRESBYTERIAN  HOSPITAL. 

Dr.  a.  H.  Smith  orders  cups  applied  to  the  chest 
and  stimulants  given  to  support  the  heart's  action. 
Oxygen  gas  is  also  used  at  times.  For  the  dyspnoea, 
however,  he  has  found  the  following  to  be,  in  many 
cases,  the  only  means  of  affording  relief : 

^.     Ext.  quebracho  fl..         .         .      m.  xx-xl. 
Sig.  Dose. 

The  effect  is  almost  instantaneous  and  frequently 
continues  for  some  time.  The  remedy  occasionally 
fails,  however,  and  is  therefore  not  specific  in  all  cases; 
but,  as  a  rule,  he  considers  quebracho  of  great  value. 


PULMONARY  GANGRENE. 


Definition. — Pulmonary  gangrene  is  character- 
ized by  the  breaking  down  of  the  lung-tissue,  and  its 
conversion  into  a  fetid,  dirty,  greenish  mass  or  matter, 
with  a  similar  discolorization  of  the  surrounding  con- 
solidated tissues. 

BELLEVUE  HOSPITAL. 

Dr.  Loomis'  treatment  is  purely  sustaining  by 
means  of  stimulants,  tonics,  and  nourishing  food, 
Opiitni  is  given  in  sufficient  doses  to  relieve  the  gen- 
eral symptoms  of  distress,  as  well  as  the  pain  and 
cough.  In  regard  to  antiseptic  inhalations,  he  is 
rather  doubtful  of  the  good  results  claimed  by  some. 
The  internal  administration  of  potassium  chlorate  he 
considers  of  no  radical  service  whatever. 

Dr.  Alonzo  Clark  believes  that  treatment  is  of  lit- 
tle avail,  although  cases  have  recovered.  He  resorts 
to  a  promptand  vigorous  defence  against  the  effects  of 
the  disease  by  supporting  the  strength  of  the  patient 
with  good,  nutritious  food,  tonics  and  medicines 
which  are  sustaining.  For  this  purpose,  while  iron 
offers  the  most  permanent  benefit,  yet  he  considers 
quinine  the  more  prompt,  believing  it  to  be  one  of 
the  best  remedies  in  this  disease,  and  orders  its  free 
exhibition,   giving  quinice  sulph.^  grs.  x.  three  times 

131 


132  PULMONARY   GANGRENE. 

daily.  He  uses  the  alcohols  carefully,  giving  them 
only  by  the  pulse  indications.  When  convalescing, 
he  requires  the  patient  to  keep  perfectly  quiet  in  bed 
and  to  avoid  all  muscular  movements ;  this  to  pre- 
vent fatal  haemorrhage  from  weakened  or  even  open 
vessels. 

It  may  not  be  out  of  place  to  mention  a  plan  of 
treatment  for  gangrene  of  the  lung  adopted  by  M. 
Raynaud  of  Charite  Hospital,  Paris.  He  speaks 
very  strongly  concerning  the  good  effects  of  eucalyp- 
tus in  this  affection,  and  mentions  two  cases  cured 
by  this  remedy.  His  mode  of  administration  is  as 
follows  : 

5.    Tinct.  eucalypt.         .         .         .      3  iss-ii. 
Sig.  Dose,  daily. 

With  this  he  combines  Trousseau's  treatment, 
which  consists  in  the  inJialation  of  terebinthince ; 
inspiration  being  effected  by  means  of  a  tube  in- 
serted in  a  bottle  of  the  essence. 


PART  II. 
DISEASES  OF  THE  HEART. 


VALVULAR  LESIONS. 


Definition.  —  An  abnormal  condition  of  the 
valves  of  the  heart,  causing  obstruction  to,  or  regur- 
gitation of,  the  current  of  blood  in  its  passage 
through  the  cavities  of  the  organ. 

BELLEVUE  HOSPITAL. 

As  a  general  rule,  Dr.  AUSTIN  Flint  considers 
that  patients  with  valvular  lesions  do  not  suffer  much 
inconvenience,  so  long  as  hypertrophy  predominates. 
He  directs  that  all  kinds  of  mental  emotion  and 
physical  exertion  which  increase  the  action  of  the 
heart,  be  carefully  avoided.  Otherwise  considerable 
muscular  exercise  may  be  indulged  in  with  advan- 
tage, but  it  is  to  be  carried  only  to  the  extent  of  not 
suffering  the  least  discomfort.  In  aortic  regurgita- 
tion, however,  active  physical  or  mental  excite- 
ment is  to  be  especially  guarded  against.  Dur- 
ing the  earlier  stages  of  heart  disease,  when  the  pa- 
tient is  apparently  well,  except  for  a  feeling  of 
oppression  and  discomfort  over  the  cardiac  region, 
very  little   is  done   in  the  way  of  treatment.     The 

133 


134  VALVULAR   LESIONS. 

various  functions  of  the  body  are  carefully  regulated, 
and  the  system  sustained  by  good,  nutritious  food. 
All  wines,  spirits,  and  tobacco  are  forbidden,  the  diet 
is  made  simple  and  nourishing,  chiefly  nitrogenous 
in  character,  and  everything  tending  to  set  up  gastric 
disturbance,  flatulence,  etc.,  rigidly  avoided.  By  the 
strict  and  regular  enforcement  of  these  measures, 
combined  with  rest,  very  great  benefit  usually  ob- 
tains. 

When  dilatation  succeeds  there  is  dyspnoea,  at  first 
upon  exertion,  then  when  at  rest,  together  with  cyan- 
osis and  more  or  less  general  dropsy.  In  such 
cases.  Dr.  Flint  considers  complete  rest  in  bed  and 
the  absence  of  all  exciting  causes  of  primary  import- 
ance. For  the  dyspncea,  he  resorts  to  the  careful 
use  of  opiates,  or  at  times  the  ethereal  preparations 
are  employed  with  relief.  The  following  is  often 
given  with  good  effect : 

]^.     Sol.  morphiai  (U.S.P.) 

Spts.  aether  co.     .  .  .  .     aa  3  i. 

M.    Dose,  a  teaspoonful. 

For  the  heart  itself,  especially  when  it  is  feeble  and 
irregular  in  action,  he  administers  tincture  of  digitalis 
in  doses  of  in.  x-xi\  This  is  given  at  short  intervals 
in  order  to  maintain  a  continuous  effect  of  the  drug. 

In  aortic  lesions,  Dr.  Flint  uses  digitalis  with  a 
certain  amount  of  reserve,  believing  that  in  some 
cases  benefit  follows  the  judicious  administration  of 
this  remedy.  He  gives  it  in  doses  sufificient  to  se- 
cure the  tonic  effect  on  the  heart  without  producing 
much  slowness  of  the  cardiac  action,  or  incurring  the 


Valvular  lesions.  135 

danger  which  some  consider  involved  in  its  use ; 
namely,  over-filling  of  the  ventricle  and  consequent 
paralysis.  He  also  advises  discretion  in  the  employ- 
ment of  digitalis  in  all  cases  of  heart  disease  ;  with  a 
powerfully  acting  heart  the  drug  does  harm.  His 
indications  for  its  use  are  weakness,  rapidity,  and 
irregularity.  In  aortic  regurgitation,  with  also  ob- 
struction, where  the  hypertrophy  is  insufficient  to 
overcome  the  dilatation,  nutrition  of  the  cardiac  mus- 
cle may  be  increased  by  the  hypodermic  injection  of 
digitaline,  gr.  j  J  ^  three  times  daily.  This,  combined 
with  small  doses  of  iron  simply  to  stimulate  the 
heart,  is  followed  by  marked  improvement. 

In  mitral  lesions,  and  when  the  tricuspid  valves 
become  Insufficient,  the  most  beneficial  effects  of 
digitalis  are  observed.  When  there  is  a  condition  of 
dyspnoea,  praecordial  pain  and  palpitation,  with 
oedema  of  the  feet  and  ankles,  digitalis  in  moderate 
dosage  combined  with  quiet  rest  in  bed  is  found  to 
be  of  great  service.  To  relieve  the  dyspnoea  Dr. 
Flint  also  uses  the  following  with  very  satisfactory 
results,  even  in  cases  of  the  severest  intensity : 

9.      Ext.  quebracho  fl.      .  .     m.  xx-xxx. 

Sig.   Dose. 

If  dizziness,  dimness  of  vision,  and  vertigo  are  also 
present,  with  marked  pallor  and  venous  pulse,  he 
resorts  to  the  careful  administration  of  stimulants, 
alcohol  and  carbonate  of  ammonium. 

To  remove  the  dropsy,  he  finds  that  hydragogue 
cathartics  and  diuretics,  employed  judiciously,  are 
very  serviceable.     When  general  anasarca  is  present 


136  VALVULAk  LESIONS.  •* 

without  dyspnoea  and  cyanosis,  Dr.  Flint  often 
causes  it  to  disappear  by  the  administration  of  the 
infusion  of  digitalis,  in  do^es  of  3  ss.  every  three  hours. 
In  some  cases  salines  are  also  given,  together  with 
alcohol  if  indicated.  Where  in  addition  to  the 
dropsy  there  is  hydrothorax  and  pulmonary  oedema, 
with  attacks  of  orthopnoea,  he  orders  dry  cupping 
applied  to  the  chest  and  the  internal  use  of  the  fol- 
lowing : 

5-     Potass,  acetat.       .         .         .         .      3  ss. 
Infus.  digitalis       .  .  .  .      §  ss. 

M.    Sig.      Dose,  every  three  hours. 

In  such  emergencies  he  also,  as  a  rule,  gives  olei 
tiglii,  gtt.  a. 

Besides  the  relief  of  the  special  symptoms.  Dr. 
Flint  directs  his  treatment  to  the  improvement  of 
the  blood  by  improving  the  general  condition  of  the 
patient.  If  anaemia  is  present  he  not  only  employs 
the  chalybeates,  but  also  administers  those  remedies 
which  assist  the  digestion  and  assimilation.  By  the 
adoption  of  these  measures,  varying  in  individual 
cases,  together  with  the  benefit  of  hospital  repose 
and  proper  management,  life  is  often  prolonged .  sev- 
eral years. 

The  following  is  very  extensively  used  at  Bellevue 
^,       Hospital : 
j~^^      9-    Sodii  bicarb.   .  .  .  .      3  i.     \ 

^  Pulv.  rhei 3  ss.       \. 

Spts.  menth.  pip.   .         .         .         .     3  ii.  ^ 

Aquae  q.  s.  ad.  .  .  .         .     §  iv. 

M.     Dose,  a  tablespoonful. 


VALVULAR   LESIONS.  1 37 

Dr.  Alonzo  Clark  advises  moderation  in  all  the 
habits  of  life.  He  directs  the  patient  to  exercise  less 
energy  than  formerly,  and  to  avoid  all  active  exer- 
tions which  accelerate  the  heart's  movement,  such  as 
fast  walking,  going  up  stairs  quickly,  etc.  For  this 
reason  he  finds  that  plethoric  persons  bear  heart  dis- 
ease better  than  the  sanguineous  who  are  more  ac- 
tive. As  the  heart  reacts  promptly  to  any  disorder 
of  digestion,  the  stomach  must  be  well  regulated, 
and  everthing  tending  to  excite  dyspepsia  and  flatu- 
lence carefully  abstained  from.  The  patient  is  in- 
structed to  eat  slowly  and  never  to  a  full  stomach  ; 
this  almost  invariably  aggravates  the  praecordial  pain. 
Alcoholic  liquors  must  be  strictly  avoided.  By  the 
observance  of  these  measures  Dr.  Clark  believes  that 
disorders  of  the  valves  maybe  carried  for  life,  needing 
no  immediate  treatment   beyond  occasional  advice. 

Where  palpitation  is  a  constant  and  persistent 
symptom,  he  gives  mix  vomica  in  small  doses,  or  ext. 
veratruni  viride  fl.,  gtt.  i.  three  times  daily.  This 
causes  the  heart  to  act  more  regularly  and  also  re- 
lieves the  oedema  when  present.  Bleeding  he  would 
never  resort  to.  If  opium  is  employed  at  all  it  is 
with  extreme  care,  especially  in  the  advanced  stage 
of  cardiac  disease,  as  coma  may  easily  supervene.  In 
such  cases.  Dr.  Clark  makes  use  of  the  following 
with  very  great  benefit : 

9-.    Chloral,  hydratis  .  .  .     grs.v. 

Potass,  bromid.   .         ,  ,  .     grs.x. 

Aquae  q.  s. 

M.     Sig.     Dose. 


138  VALVULAR   LESIONS. 

This  he  gradually  increases  until  double  the  amount 
is  taken.  For  the  stomach  affection,  he  prescribes 
nitro-muriatic  acid  with  pepsin.  The  following  com- 
bination is  employed  at  this  hospital : 

9-    Pepsini     .....  grs.  Ixiv. 

Aquae        .....  §  i'ss. 

Acid,  hydrochlorici            .         .  .    3  ss. 

Glycerinae         .          .         .         . '  §  iss. 
M.  et  filt. 

For  marked  intermission  of  the  heart  occurring  in 
organic  disease,  if  any  medication  is  possible  he  gives 
preference  to  the  alcohol  treatment. 

In  the  early  stage  of  mitral  disease  when  the  appe- 
tite is  good,  with  no  flatulence  or  disturbance  of  di- 
gestion, he  is  not  inclined  to  administer  digitalis ;  in 
these  cases  his  treatment  is  mainly  advice.  When 
associated  with  renal  disease,  if  the  heart  is  regular 
in  its  action,  and  with  no  special  indication  for  treat- 
ment, he  endeavors  to  relieve  the  kidney  lesion  by 
placing  the  patient  on  the  use  of  iron,  combined 
with  the  administration  of  diuretics.  The  following 
is  very  often  used  by  him  for  this  purpose  : 

5.     Potass,  acetat. 

Infus.  digitalis      .  .  .     aa  3  ii-iv. 

M.     Sig.     This  amount  daily. 

By  this  means  the  cardiac  symptoms  and  the  attend- 
ing distress  are  usually  promptly  relieved. 

It  is  mainly  when  dilatation  succeeds  and  venous 
obstruction  occurs,  causing  systemic  congestions  fol- 
lowed by  oedema  of  the  lungs  with  dropsical  and 


^  VALVULAR   LESIONS.  1 39 

pleuritic  effusions,  that  energetic  measures  are 
adopted.  Under  these  circumstances,  Dr.  Clark 
finds  the  vapor  bath  very  efficacious  (if  the  patient 
can  bear  it),  followed  by  a  profuse  sweating  induced 
by  wrapping  in  blankets,  and  assisted  in  the  morn- 
ing by  friction  apphed  with  a  dry  flannel  over  the 
entire  body.  This  he  repeats  two  or  three  times  a 
week.  Digitalis  infusion  is  also  given.  He  also  acts 
on  the  kidneys  by  means  of  the  salines,  using  the 
above  prescription  ;  or  a  sohition  of  potassium  bitar- 
trate,  O  i.  to  be  taken  daily.  Or  he  frequently  em- 
ploys the  mineral  waters  for  this  purpose,  especially 
Kissengen,  giving  a  glassful  three  times  a  day.  The 
following  diuretic  pill  is  a  favorite  with  Dr.  Clark, 
and  often  used  with  gratifying  effect : 

5.    Pulv.  digitalis 
Pulv.  scillae 
Hydrarg.  chlor.  mit.      .         .         aa  gr.  i. 

M.    ft.  pil.  No.  i. 

Sig.  To  be  taken  three  times  daily. 

Where  the  patient  is  strong  and  able  to  bear  the 
sweating,  he  administers  : 

5.    Tinct.  jaborandi     .         .  gtt.  xv-xx. 

Aquae  q.  s. 

M.  Sig.  Dose,  at  night, 
with  excellent  effect.  Regarding  cathartics,  he  con- 
siders them  objectionable  ;  if  used  at  all,  only  those 
which  have  the  least  depressing  effect  should  be 
employed.  In  one  instance  the  following  was  pre- 
scribed by  him,  with  decided  benefit,  for  a  period  of 
one  year : 


I40  VALVULAR   LESIONS. 

;p.  Potass,  et  sodii  tart.  .  .  •  5  !• 
Ext.  senn^  fl.  .  .  .  .  3i. 
Aquae  q.   s. 

M.   Sig.     Dose,  every  other  day. 

For  the  heart,  digitalis  is  given  in  doses  sufficient 
to  regulate  the  cardiac  action.  Dr.  Clark  also 
endeavors  to  enrich  the  blood  by  good,  nutritious 
food,  combined  with  the  administration  of  chalyb- 
eates.  By  these  means,  together  with  perfect  quiet 
and  rest  in  bed,  marked  improvement  in  the  general 
system  follows,  often  very  rapidly,  and  with  great 
relief  from  the  cardiac  symptoms. 

Dr.  Fordyce  Barker  makes  use  of  the  follow- 
ing with  excellent  effect,  where  there  is  flatulence 
and  oppression  after  eating.  He  considers  it  one  of 
the  most  agreeable  and,  at  the  same  time,  most  suc- 
cessful of  his  prescriptions. 

]^.    Pepsini 3  ii. 

Acid,  hydrochlor.  dil.          .         .  3  i. 

Aquae  menth.      ....  5  iii. 
M.    f^lt.  et  add. 

Syrup,  aurantii  cort.  .         .          .  31. 
Sig.   A  tablespoonful   in  water  immediately  after 
eating. 

When  anaemia  is  marked,  and  with  much  nervous 
irritability  and  depression  present,  the  following 
combination  is  found  by  Dr.  Barker  to  afford 
remarkable  benefit  : 

I^.    Acid,  phosphoric,  dil.  .         .       5  ss. 


VALVULAR  LESIONS.  I4I 

Tinct.  ferri  chlor.  .         .         .         §  i, 

Strych.  sulph.       .         .         .  .     gr.  i. 

M.    et  add. 

Glycerinae     .....§  iss. 

Syrup,  aurantii  cort.     .  .  .         5  i- 

Sig.   A    tablespoonful  in    a   wineglass    of    water 
directly  after  eating,  taken  through  a  tube. 

In  the  treatment  of  cardiac  disease,  Dr.  Loomis 
considers  rest  in  bed  and  the  avoidance  of  all  excit- 
ing influences,  both  physical  and  mental,  to  be  of 
primary  importance.  The  diet  is  made  nutritious, 
principally  nitrogenous,  and  given  frequently  in 
small  amounts  ;  everything  promoting  flatulent  dys- 
pepsia being  carefully  guarded  against.  In  many 
instances  his  treatment  is  for  the  most  part  purely 
hygienic.  With  this  he  gives  iron  daily,  especially 
if  anaemia  is  present.  When  there  is  failure  of  the 
heart  power,  evidenced  by  oedema  of  the  feet,  etc., 
digitalis  is  employed  by  Dr.  Loomis  both  in  aortic 
and  mitral  lesions,  with  marked  service.  The  infus- 
ion is  preferred  and  given  in  doses  sufficient  to  fur- 
nish compensation.  In  mitral  disease  this  not  only 
relieves  the  pulmonary  but  also  the  systemic 
obstruction.  When  dropsy  is  present,  he  finds  digi- 
talis exceedingly  valuable  as  a  diuretic.  For  this 
purpose  he  frequently  resorts  to  large  doses,  some- 
times requiring  of  the  infusion  of  digitalis,  1,ss.  every 
three  hours,  to  control  and  regulate  the  circulation. 
Cathartics  are  also  employed,  at  times,  to  relieve  the 
surcharged  veins.  Excellent  use  is  also  made  of  the 
iron  preparations  in  these   cases,  but  more  particu- 


142  VALVULAR   LESIONS. 

larly  in  anaemic  patients,  the   following  method  of 
administration  being  preferred  by  him  : 

9.     Pil.  ferri  carbon.         .         .         grs.  x-xx. 

Sig.  Dose,  three  times  daily,  with  the  food. 

When  there  is  a' condition  of  general  anasarca,  he 
resorts  to  puncture  as  the  only  means  of  relief. 

As  a  subsequent  treatment  Dr.  LOOMIS  advises 
that  the  patient  lead  a  quiet  life,  free  from  all  undue 
physical  or  emotional  excitement,  and  that  intem- 
perance, both  in  eating  and  drinking,  be  carefully 
avoided.  He  considers  it  of  the  highest  importance 
that  failure  of  the  heart  power  be  prevented  by 
rigidly  abstaining  from  everything  which  calls  the 
heart  into  active  exercise.  Where  there  is  a  rheu- 
matic history,  the  patient  is  advised  to  resort  to  a 
climate  offering  the  least  liability  of  a  recurrence  of 
the  rheumatic  attack. 

Dr.  W.  H.  Thomson  considers  the  hygienic  man- 
agement of  these  patients  to  be  of  vital  importance. 
In  many  instances  where  there  has  been  a  condition 
of  praecordial  pain  with  palpitation,  great  dyspnoea 
on  exertion,  more  or  less  cough,  and  possibly  night- 
sweats,  he  has  observed  remarkable  improvement  to 
follow  upon  the  change  of  life  and  the  care  and  atten- 
tion afforded  by  hospital  discipline.  When  indicated 
he  administers  digitalis  in  form  of  the  infusion,  three 
times  daily,  and  in  sufficient  amount  to  relieve  the 
disturbance  to  the  circulation.  In  the  later  stages, 
when  dropsy  is  present  with  pleuritic  effusion  and 
intense  dyspnoea,  he  orders  digitalis  and  potas- 
sium acetate  as  a  diuretic,  together  \N\\h.  fluid  extract 


VALVULAR   LESIONS.  I43 

of  jaborandi,  Zss.,at  night.  At  times  th.Q  kot-air 
bath  is  made  use  of  ;  or  as  a  final  resort  the  body  of 
the  patient  is  thoroughly  oiled,  and  then  wrapped  in 
blankets  saturated  with  hot  water.  This  is  supported 
by  the  hypodermicMnjection  oi  pilocarpine,  gr.^^. 
If  the  bowels  are  constipated,  gtt.  ii.  of  croton  oil  diYo. 
given  in  pill  form.  Should  this  have  no  effect  he 
resorts  to  the  following,  repeated  if  necessary  : 

]^.    Hydrarg.  chlor.  mit.         .         .     grs.  xv. 

-        Ext.  jalapae      .  .  .  .       grs.  x. 

Sig.     Dose. 

If  the  bowels  still  refuse  to  move,  in  addition  to 
this  he  administers,  by  injection,  elaterin,  gr.  ^^-^ 
every  hour  for  three  or  four  hours.  By  either  or  all 
of  these  means,  Dr.  Thomson  usually  succeeds  in 
obtaining  free  diaphoresis.  Should  this  not  prove 
sufficiently  abundant,  however,  he  assists  by  the  in- 
jection oi  pilocarpine,  gr.  ^Q,  continued  every  hour 
until  gr.  ss.  has  been  given.  When  dropsy  alone  is 
present  without  the  more  urgent  symptoms,  jabo- 
randi  is  very  often  employed  in  doses  of  3  ss-i.,  with 
excellent  effect  ;  relief  is  usually  prompt  and  lasting 
for  many  hours. 

In  children,  where  shortness  of  breath  on  exertion 
is  the  only  symptom  complained  of,  no  special  indi- 
cation for  treatment  is  called  for.  The  mode  of  liv- 
ing, the  diet,  and  the  various  functions  of  the  body 
are  regulated  ;  the  nutrition,  if  the  appetite  is  poor, 
sustained  ;  and,  especially  if  anaemia  is  present,  iron 
and  quinine  are  given,  together  with  cod  liver  oil  if 
there  is  a  loss  of  flesh.     In  such  cases,  it  is  advised 


144  VALVULAR   LESIONS. 

that  rest  out  of  school  for  a  season  is  often  of  great 
benefit. 

In  the  treatment  of  heart  disease  in  children,  asso- 
ciated with  chorea,  Dr.  THOMSON  considers  zinc 
and  arsenic  most  serviceable  ;  of  these  he  prefers 
zinc,  commencing  with  zinci  sulphat.,  gr.  i.,  and 
increasing  the  amount  until  nausea  is  produced.  By 
this  means  he  has  frequently  seen  marked  improve- 
ment within  a  week.  For  the  abnormal  condition  of 
the  nervous  system,  with  faulty  nutrition,  anaemia, 
etc.,  he  finds  the  following  prescription  of  great 
value : 

]^.    Quiniae  sulph.  .  .  grs.  xx. 

Ferri  lactatis  .  .  grs.  xx. 

Pulv.  carb.  lig.  .  .  grs.  xl. 

M.   ft.  pulv.  No.  XX. 

Sig.     One,  three  times  daily  in  cod  liver  oil. 

He  also  advises  that  the  general  treatment  be  con- 
tinued for  several  months,  even  though  marked  im- 
provement takes  place. 

In  choreic  cases.  Dr.  E.  G.  Janeway  places  most 
reliance  on  strychnia,  given  in  small  doses,  and  con- 
tinued for  a  considerable  period  or  time.  If  anaemia 
is  also  present  he  administers  iron. 

NEW  YORK   HOSPITAL. 

In  the  treatment  of  organic  disease  of  the  heart. 
Dr.  Wm.  H.  Draper  considers  rest  the  cardinal 
principle.  This  must  be  absolute  and  in  bed,  to  se- 
cure which  the  most  stringent  rules  are  enforced. 


VALVULAR  LESIONS,  I45 

Excitement  of  all  kinds  must  be  abstained  from,  and 
everything  tending  to  irritate  the  action  of  the 
heart  carefully  avoided.  The  dietetic  regimen  he 
makes  equally  important,  and  discards  all  the  old 
treatment  of  gruels,fruits,  sweets,  etc.,  as  especially 
harmful.  No  whiskey  or  wines  are  allowed.  The 
food  is  concentrated  and  chiefly  nitrogenous,  consist- 
ing of  milk  and  animal  foods,  and  avoiding  all  sub- 
stances which  undergo  acid  fermentation  in  the 
stomach.  By  thus  relieving  the  dyspeptic  symp- 
toms the  tendency  to  cardiac  disturbance  is  very 
materially  lessened. 

For  the  heart,  digitalis  is  employed  with  the 
greatest  benefit,  but  its  administration  should  not 
commence  so  long  as  the  hypertrophy  affords  com- 
pensation. 

In  aortic  insufficiency,  however.  Dr.  Draper  con- 
siders digitalis  dangerous.  As  the  regurgitation  of 
the  blood  takes  place  during  the  cardiac  diastole,  the 
effect  of  this  drug  would  be  to  increase  regurgitation 
by  lengthening  this  diastole,  from  which  the  ventri- 
cle, thus  over-distended  by  the  two  streams  of  blood, 
might  be  unable  to  recover  itself.  The  use  of  digi- 
talis, therefore,  only  aggravates  the  constant  danger 
from  syncope  from  anaemia  of  the  brain,  which 
obtains  in  this  lesion.  He  makes  no  absolute  rule, 
however.  In  some  instances,  he  finds  that  cautious 
dosage  may  afford  benefit  by  increasing  the  heart's 
action,  but  dizziness  and  distress  are  very  apt  to  fol- 
low. When  insufficiency  at  the  mitral  valve  is  also 
present,  the  administration  of  digitalis  causes  no  un- 


146  VALVULAR  LESIONS. 

pleasant  effects  from  the  aortic  complication  ;  but, 
on  the  contrary,  by  regulating  the  cardiac  action  and 
strengthening  it,  actual  good  results.  Opium  is  be- 
lieved by  Dr.  Draper  to  be  most  valuable  in  aortic 
regurgitation.  Morphia,  he  advises,  increases  the 
force  without  diminishing  the  frequency  of  the 
heart ;  and,  probably  producing  cerebral  hyperaemia, 
it  is  therefore  indicated  when  there  is  a  condition  of 
dizziness,  cerebral  anaemia,  and  a  tendency  to  syn- 
cope. If  angina  pectoris  is  also  present,  he  finds 
that  morphia  exerts  a  specific  influence.  The  hypo- 
dermic method  of  administration  is  preferred,  acting 
with  more  promptitude. 

In  mitral  lesions  he  finds  digitalis  is  extremely  ser- 
viceable, giving  infus  digitalis  3  i-iii.  three  times 
daily.  This  slows  and  regulates  the  heart's  action, 
increases  its  force,  preserves  the  arterial  tension,  and 
has  a  specific  action  on  the  sympathetic  cardiac 
plexus.  Hence,  in  these  patients  having  dyspnoea, 
cough,  and  rapid,  feeble,  and  irregular  pulse,  digitalis 
is  especially  indicated.  In  stenosis  it  affords  benefit 
by  lengthening  the  diastole,  giving  time  for  the  left 
ventricle  to  fill,  and  thus  relieves  the  effect  of  the 
obstruction.  In  mitral  insufficiency  the  use  of  digi- 
talis by  prolonging  the  diastole  allows  the  ventricle 
to  fill  more  completely,  while  at  the  same  time  it  in- 
creases the  systolic  power.  But  caution  is  advised 
in  its  administration,  lest  from  a  too  early  or  too 
frequent  use  the  heart  muscle  soon  fail  to  derive  its 
beneficial  effects.  When  the  pulse  is  suf^cient, 
though  feeble,  digitalis  is  not  indicated.    For  admin- 


VALVULAR  LESIONS.  I47 

istration,  the  infusion,  if  made  from  3  i-ii-Oi.  is  pre^ 
ferred  to  the  tincture.  Iro7i  is  also  employed,  es- 
pecially  where  anaemia  is  present,  and  with  great  as- 
sistance to  the  heart.  The  following  is  the  formula 
for  Blaud's  pill,  used  at  this  hospital : 

9.     Ferri  sulph. 

Potass,  carb.  .  .         aa.  grs.  iiss. 

M.     ft.  pil.  No.  i. 

When  dropsy  is  a  prominent  symptom,  absolute 
rest  is  insisted  upon, and  the  diet  carefully  regulated. 
Dr.  Draper's  treatment  depends  largely  upon  nu- 
trition to  improve  the  quality  of  the  blood,  and  in- 
crease the  eliminating  power  of  the  kidneys  and 
bowels.  This  he  considers  far  better  than  any  vio- 
lent diuretic  or  diaphoretic  measures.  He  therefore 
relieves  the  anaemic  condition  with  iron,  tonics,  and 
good,  nutritious  food  ;  at  the  same  time  an  occa- 
sional purge  is  given  with  good  effect,  together 
with  diuretics.  The  following  tonic  mixture  is  kept 
constantly  on  hand : 

9.     Strych,  sulph.  .  .  .     grs.  viii. 

Cinchonidiae  sulph.  .         .  J  i. 

Tinct.  ferri  chlor.  .         .  ^  vi. 

Tinct.  zingib.  .        .         .  3  ii. 

Glycerins 

Acid,  phosphoric,  dil.     .  .      aa.  ^xvi. 

M.    Sig.   A  teaspoonful  three  times  daily. 

The  digitalis  is  also  continued,  and  is  usually  very 
serviceable.  Acetate  of  potassium  is  often  used,  or, 
where  diuretics  are  not  tolerated, y^^i??'^?^^/ is  given, 


148  VALVULAR  LESIONS. 

the  following  method  of  hypodermic  administration 
being  frequently  resorted  to : 

]p,.     Pilocarpinae  mur.  .         ,  gr.  i. 

Aquae  distil,  carbol.  .         .         m.   1. 

M.     Dose,  ten  minims. 

Bandaging  of  the  limbs  is  also  employed  in  certain 
cases. 

In  the  later  stages  of  cardiac  dropsy,  however, 
with  general  anasarca  present,  when  these  measures 
fail  or  are  too  slow  in  action,  still  much  is  done  to 
render  the  patient  comfortable.  The  connective  tis- 
sue is  tapped  in  various  situations,  several  7iecdle- 
piinctiircs  being  made  in  the  most  oedematous  por- 
tions, by  which  means  considerable  fluid  is  drawn  off, 
giving  relief  from  what  seemed  impending  death. 
Opium  is  also  given.  This  is  usually  attended  with 
success,  sometimes  complete  reduction  of  the  fluid 
occurring  within  a  few  days.  The  procedure  is  an 
extremely  disagreeable  one,  although  often  affording 
the  only  relief,  and  Dr.  DRAPER  advises  that  it  be 
practiced  with  great  care.  A  fine  needle  is  selected 
and  puncture  made,  as  a  rule,  somewhere  below  the 
knee,  as  here  it  is  less  liable  to  give  rise  to  bad 
effects.  Sometimes  the  thighs  are  also  made  use  of, 
and  occasionally  the  abdomen  and  scrotum.  After 
which  the  part  is  carefully  washed,  dressed  with 
ointment,  and  the  surrounding  integument  well  pro- 
tected from  the  fluid.  If  the  bedding  is  allowed  to 
get  saturated,  the  skin,  which  is  peculiarly  sensitive 
in  this  moistened  condition,  becomes  irritated  and 
inflamed,  setting  up  erythema. 


i 


VALVULAR   LESIONS.  I49 

By  these  and  other  measures  peculiarly  adapted  to 
individual  cases,  and  under  the  influence  of  hospital 
discipline  together  with  rest,  good  diet  and  medica- 
tion, these  patients  very  speedily  improve  and  are 
quite  well  for  a  time. 

Regarding  the  subsequent  treatment,  that  is  to  say, 
when  the  patient  is  in  the  best  possible  condition  and 
able  to  be  about.  Dr.  Draper  requires  the  careful 
avoidance  of  all  kinds  of  exertion,  all  undue  excite- 
ment, etc.,  both  of  the  physical  and  of  the  moral 
state.  He  directs  the  patient  to  lead  a  quiet  life, 
engaged  in  some  mental  occupation,  or  in  the  very 
lightest  manual  labor,  where  no  inordinate  strain 
shall  be  demanded  to  disturb  the  heart's  action.  He 
also  gives  strict  injunctions  regarding  food.  It  is 
especially  desirable  that  everything  tending  to  pro- 
duce flatulence  should  be  avoided.  For  a  carnmia- 
tive  the  following  is  very  extensively  employed  at 
this  hospital  with  excellent  effect : 

5.    Tinct.  opii  ....      gtt.xx. 

01.  anisi 

01.  caryophyl. 

01.  gaulth aa  gtt.ii. 

Tinct.  asafoetid.  .         .         .         fl.  3  i- 

Magnes.  carbon.        .         .         .  3  i. 

Aquae  menth.  pip.      .         .         .       fl.  §  iii. 
M. 

Intemperance,  both  in  eating  and  drinking,  is  to 
be  abstained  from,  and  the  food  must  be  simple,  but 
of  the  most  nutritious  quality.  This  he  believes  to 
be  of  primary  importance.     Especial  guard  is  there- 


150  VALVULAR   LESIONS. 

fore  to  be  made  against  dyspepsia;  more  particularly- 
acid  dyspepsia.  Quantities  of  carbonaceous  foods 
should  never  be  allowed,  thus  excluding  sweets,  far- 
inaceous and  all  fattening  foods  which  are  calculated 
for  those  who  exert  considerable  muscular  energy. 
Alcohol  in  any  form  is  harmful  and  must  never  be 
taken. 

These  minute  details  Dr.  Draper  considers  of 
vastly  more  importance  than  the  administration  of 
drugs.  He  also  derives  much  benefit,  however,  by 
an  occasional  purgation  or  diuresis,  relieving  a  gener- 
alized congestion.  Or  heart  tonics  may  often  be 
required  ;  of  these  he  finds  digitalis  of  the  greatest 
value.  But  he  urges  that  especially  by  the  judicious 
management  of  cardiac  diseases  there  is  much  to  be 
accomplished,  and  its  importance,  he  thinks,  cannot 
well  be  magnified. 

PRESBYTERIAN  HOSPITAL. 

When  there  is  a  condition  of  oedema,  with  more 
or  less  dyspnoea  present,  Dr.  F.  A.  BURRALL  gives 
strycJinicE  snlpJi.  gr.  ^^  three  times  daily,  together 
with  infusion  of  digitalis  3  ss.  three  times  a  day.  This  is 
usually  very  effectual.  But  in  the  later  stages,  where 
there  is  pulmonary  cedema  and  hydrothorax  with 
orthopncea  and  cyanosis,  when  digitalis  ceases  to  be 
of  service,  Dr.  A.  H.  Smith  has  obtained  almost 
immediate  relief  from  the  dyspncea  and  distress,  by 
the  administration  of  ext.  qiiebraeho  fl.,  in.  xxx-xl. 
In  some  instances,  however,  this  remedy  has  failed. 


VALVULAR  LESIONS.  151 

ROOSEVELT  HOSPITAL. 

In  the  early  stages,  as  long  as  the  lesion  causes  no 
interference  with  the  natural  function  of  the  heart, 
Dr.  Francis  Delafield  does  not  consider  medicin- 
al treatment  indicated.  He  directs  that  rest  and 
quiet  be  obtained,  with  abstinence  from  all  possible 
exertions,  etc.  When  drugs  are  called  for,  he  places 
most  reliance  on  potassium  iodide,  administered  in 
doses  sufficient  to  regulate  the  heart's  action ;  he 
usually  gives  potassii  iodidi^  grs.  x.  t  J  tree  times  daily, 
continuing  it  for  some  time.  The  following  tonic  is 
much  used  at  this  hospital : 

^.    Strychnise  sulph.       .  .         .     grs.  xvi. 

Tine,  ferri  chlor.        .         .         .  §  xii. 

Syrup,  simp.     .... 

Aquae  .         .         .         .       aa.  Oiv. 

M.    Sig.     Two  teaspoonfuls. 

ST.  LUKE'S  HOSPITAL. 

When  there  is  a  condition  of  venous  obstruction 
with  increasing  dyspnoea,  oedema,  cyanosis,  and 
attacks  of  orthopnoea,  acetate  of  potassium  with  infu- 
siott  of  biichu  is  ordered,  and  poultices  of  digitalis 
leaves  applied  to  the  chest.  If  pulmonary  oedema  su- 
pervenes, dry  cups  are  used  repeatedly  until  relieved. 
In  many  instances  Dr.  G.  G.  Wheelock  finds 
fluid  extract  of  quebracho  in.xx-Zss.  three  times 
daily  of  rare  service  in  relieving  the  dyspnoea  when 
all  other  remedies  fail. 


152  VALVULAR   LESIONS. 

MT.  SINAI  HOSPITAL.- 

In  children,  when  the  heart  lesion  is  dependent 
upon  chronic  pulmonary  obstruction,  iron  is  given, 
sometimes  in  form  of  the  syrup  of  the  iodide.  Dr. 
JacoBI,  however,  prefers  the  pyrophosphate,  or 
dialyzed  iron,  especially  where  anaemia  is  marked. 
To  regulate  the  heart's  action,  he  administers  yfz//<3? 
extract  of  digitalis,  in.  ii.,  three  times  a  day.  Where 
gastric  disturbance  is  present,  the  subnitrate  of  bis- 
muth is  employed  with  good  effect.  If  epistaxis  is 
prominent,  which  not  infrequently  happens,  depend- 
ing on  the  heart  lesion,  he  often  controls  it  by  the 
use  of  iron  and  digitalis.  When  there  is  a  condition 
of  oedema  of  the  lungs  with  more  or  less  general 
anasarca,  severe  dypsnoea  and  cyanosis,  digitalis  is 
given  together  with  inhalation  of  oxygen.  Should 
these  measures  fail,  infusion  of  jab  or  audi,  Ziss.pro 
re  nata,  is  administered,  and  often  with  prompt  relief. 

In  cases  of  heart  disease  associated  with  chorea 
minor.  Dr.  Jacobi  places  the  child  upon  a  course  of 
iron,  avoiding  those  preparations  which  act  as  vascular 
irritants,  such  as  themuriated  tincture,  or  tincture  of 
the  chloride.     He  gives  : 

9.    Ferri  pyrophosphat.       .  grs.  xx-xxiv. 

Sig.   This  amount  daily. 

Digitalis  is  also  employed,  either  the  fnid  extract 
m.ii-iv.  in  twenty-four  hours,  or  an  equivalent 
amount  of  the  tincture.  To  control  the  chorea  itself, 
which  is  considered  a  highly  important   feature,  he 


VALVULAR   LESIONS.  1 53 

finds  arsenic  superior  to   other  remedies,  using  the 
sodium  or  potassium  salt,  as  follows  : 

5"     Liq-  potassii  arsenit.       .         .         gtt.  iii. 

Aquae  q.  s. 
Sig.  Dose,  three  times  daily,  after  meals. , 

This  he  gradually  increases,  if  necessary,  up  to  gtt. 
vi.  When  the  muscular  twitchings  persist  during  the 
night-time  so  that  the  sleep  is  disturbed,  it  being 
exceedingly  desirable  that  these  patients  should  rest 
well.  Dr.  Jacobi  makes  use  of  the  following  with 
excellent  service  : 

]^      Chloral  hydrat.        .         .         .         grs.  xv. 
Potass,  bromid.      .         .  grs.  xv-xxv. 

Sig.  Dose,  at  bed-time. 


PERICARDITIS. 


Definition. — An  inflammation  of  the  fibro-serous 
membranous  sac  which  envelops  the  heart,  and  the 
great  vessels  at  their  passage  from  or  into  the  organ. 

BELLEVUE  HOSPITAL. 

The  essential  element  in  the  treatment  of  pericar- 
ditis is  directed  to  the  condition  with  which  it  is 
associated.  In  all  cases  of  acute  rheumatism  Dr. 
AlONZO  Clark  considers  it  of  the  greatest  import- 
ance to  examine  the  heart.  He  finds  that  the  car- 
diac lesion,  as  a  rule,  follows  the  rheumatic  attack 
about  the  fifth  day ;  therefore  he  endeavors  to  effect 
an  early  cure  of  the  articular  affection,  and  thus,  if 
possible,  prevent  the  pericarditis.  The  patient  is 
placed  on  the  alkaline  treatment,  or  upon  the  salicy- 
late of  soda,  in  doses  of  grs.  xv-xx.  every  two  or  three 
hours.  This  during  the  first  day,  and  the  same 
amount  once  in  three  or  four  hours  on  the  second 
day.  By  this  means  he  frequently  succeeds  in  con*, 
trolling  the  rheumatism  in  a  few  hours  ;  usually  within 
two,  three  or  four  days.  Where  the  drug  disagrees, 
causing  vomiting,  it  is  administered  by  injection.  If 
a  blister  is  needed,  this  is  applied  at  the  border  of 

154 


PERICARDITIS.  155 

the  diaphragm  and  upward  ;  or  he  sometimes  gets 
rid  of  the  effusion  by  means  of  iodine  apphed  over 
the  cardiac  region.  Opium  is  also  given  in  doses 
sufficient  to  ease  the  heart  and  correct  its  short, 
irritant  beat. 

In  idiopathic  cases,  Dr.  Clark  apphes  a  bhster  to 
the  praecordium,  and  if  the  pulse  is  full  and  strong  a 
laxative  is  given.  In  full-blooded  patients  he  some- 
times resorts  to  venesection^  drawing  blood  to  3  vi-xii. 
Complete  rest  is  also  enjoined,  together  with  a  care- 
fully regulated  diet  and  avoidance  of  all  exposure. 

The  following  salicylic  acid  mixture  is  used  at  this 
hospital : 

9.    Acid,  salicylici        .  .         grs.  clx. 

Potass,  acetat.  .  .         .   grs.  cccxx. 

Glycerinae        .  .  .         .  A-  3  i- 

Aquae  q.  s.  ad  .  .  .  fl.  3  iv. 

M.    Dose  :  A  teaspoonful  to  a  tablespoonful. 

Dr.  Loomis  confines  the  patient  to  bed,  and 
enforces  absolute  rest  and  quiet.  Hot  anodyne 
poultices  are  applied  over  the  prsecordial  region, 
usually  affording  great  relief.  Internally  he  gives 
opium  in  small  doses  to  relieve  the  pain.  Opium  i*^ 
also  preferred  by  him  for  its  action  on  th.e  heart.  For 
this  purpose,  the  irritability  being  more  marked 
during  the  night  and  the  patient  also  more  restless, 
larger  doses  are  required  at  that  time ;  but  he  par- 
ticularly cautions  against  producing  any  narcotic 
effects.  For  the  effusion.  Dr.  LoOMiS  resorts  to  the 
same  means  of  treatment  which  he  prescribes  in 
pleurisy.      Iron    and   stimulaitts    are    administered 


156  PERICARDITIS. 

together  with  a  highly  nutritious  diet,  avoiding 
everything  which  tends  to  quicken  the  action  of  the 
heart.  During  convalescence  careful  attention  to 
hygiene  is  advised.  As  regards  aspiration,  if  certain 
that  pus  is  present  he  would  not  hesitate ;  but  in  all 
other  instances*  he  advises  the  most  careful  consider- 
ation before  resorting  to  such  a  procedure. 

In  addition,  his  treatment  is  also  directed  toward 
the  condition  upon  which  the  pericardial  affection 
depends,  e.  g.,  rheumatism,  etc.  Occurring  in  fevers, 
especially  of  the  pyaemic  and  septic  type,  with  much 
depression  of  the  vital  powers,  free  stimulation  and 
sustaining  measures  are  employed. 

In  Dr.  Austin  Flint's  wards  the  treatment  also 
varies  with  the  primary  condition,  and  according  to 
the  amount  of  effusion  present  and  the  intensity  of 
the  inflammation,  as  denoted  by  the  general  and  local 
symptoms.  He  considers  rest  and  quiet  essential 
points  in  the  treatment.  Occurring  with  rheumatism 
he  places  the  patient  on  the  following: 

^.    Mist.  acid,  salicylic,  (grs.  xlv- 3  i)     .      §  ss. 

Sig.  Dose,  every  three  hours. 

Dr.  Flint  has,  however,  noticed  that  since  the 
use  of  salicylic  acid  in  rheumatism,  cardiac  affections 
have  become  more  common  than  before.  Therefore 
he  believes  it  to  be  of  the  greatest  importance,  when 
prescribing  the  salicylic  acid  treatment,  to  administer 
the  alkalies  in  sufficient  quantity  to  render  the  urine 
alkaline  as  speedily  as  possible,  with  a  view  to  dimin- 
ishing the  liability  to  the  cardiac  affection.  If  this 
is  done  at  the  onset  of  the  rheumatic  attack,  he 


PERICARDITIS.  15/ 

thinks  it  very  probable  that  the  heart  trouble  would 
not  occur.  For  this  reason,  therefore,  with  the  above 
he  also  gives  sodii  bicai^bon.    Z^s.  every  three  Jwitrs. 

Besides  these  means  of  treatment,  if  the  effusion 
is  abundant,  he  resorts  to  diuretics  and  cathartics, 
but  avoiding  any  considerable  general  debility.  For 
a  diuretic  he  often  uses  the  following : 

]^.     Potass,  acetat.      .         .  ,  .       3  ss.        " 

■   Infus.  digitalis       .  .  .  .       J  ss. 

M.     Sig.     Dose,  every  four  hours. 

,  Sometimes  he  applies  counter-irritation  by  means 
of  blisters  or  iodine,  with  beneficial  effect.  If  pain 
is  prominent  it  is  relieved  by  opium.  He  also  con- 
tinues the  use  of  the  alkalies  to  prevent,  if  possible, 
the  inflammation  increasing.  The  diet  is  made  nutri- 
tious and  sustaining  without  exciting  the  heart's 
action. 

The  following  is  used  at  this  hospital  as  an  anti- 
rheumatic : 

5.     Sodii  et  potass,  tart.      .  .  .      3  ss. 

Potass,  nitrat.         .  .  .  .       3  v. 

Vin.  colchici  sem.  .  .         .  fl.  3  ii. 

Aquae  q.  s.  ad         .  .  .  .  fi.  5  ii. 

M.     Dose:  A  teaspoonful. 

NEW  YORK  HOSPITAL. 

Dr.  W.  H.  Draper's  treatment  is  based  on  the 
accompanying  condition.  If  the  pericardial  compli- 
cation arises  in  the  course  of  rheumatic  fever,  he  pre- 
scribes salicylic  acid  in  doses  of  grs.  xv-xx,  every  tzvo 


158  PERICARDITIS. 

hours.  This  is  continued  until  3  ii.  have  been  taken, 
and  is  usually  followed  by  very  gratifying  results. 
Sometimes  the  soda  salt  is  used  instead.  Absolute 
rest  is  also  considered  of  great  importance.  To  ob- 
tain this  he  not  only  directs  that  the  most  stringent 
rules  be  enforced,  but,  if  necessary,  opium  is  also 
given  in  doses  sufificient  for  this  purpose.  For  the 
pericardial  affection  counter-irritation  is  employed 
when  indicated,  together  with  the  internal  adminis- 
tration of  opium  and  digitalis  ;  this  he  finds  not  only 
controls  the  pain,  but  alleviates  the  irritable  dyspnoea 
and  the  general  cardiac  distress.  Not  infrequently 
the  dyspnoea  is  found  to  be  due  to  distension  of  the 
stomach  with  gas ;  this  he  corrects  by  the  use  of 
ammonium  carbonate.  Either  the  muriate  or  carbon- 
ate of  ammonia  is  also  given  to  keep,  if  possible,  the 
fibrin  in  solution.  Should  the  effusion  become  so 
great  as  to  cause  excessive  dyspnoea,  paracentesis  is 
resorted  to.  Dr.  Draper  does  not  believe  that 
mercury  has  any  specific  effect- regarding  the  fibrinous 
exudation.  The  diet  is  made  nutritious  in  quality, 
at  the  same  time  everything  tending  to  produce  flat- 
ulent dyspepsia  being  carefully  avoided.  The  fol- 
lowing diuretic  pill  is  much  used  at  this  hospital: 

5,.     Pulv.  scillae 

Pulv.  digitalis 

Massae  hydrarg.      .         .         .         aa  gr.  i. 
M.  ft.  pil.  No.  i. 

As  an   anti-rheumatic   the  following  is  frequently 
employed  : 


PERICARDITIS.  1 59 


1^.     Potass,  iodidi 

Vin.  colchici  sem. 
Tinct.  cimicifug.  rac. 
Tinct.  stramon. 
Tinct.  opii  camph. 


3v. 

§ss. 
^  iss. 


M.     Dose  :  A  teaspoonful  three  times  daily. 

PRESBYTERIAN    HOSPITAL. 

Besides  the  usual  measures  adopted  for  this  affec- 
tion, local  blood-letting  is  employed.  When  the 
praecordial  pain  is  most  intense,  from  one  to  three 
leeches  are  applied  over  the  apex  of  the  heart  and 
blood  to  the  amount  of  §  ss-i.  drawn.  This  gives 
the  greatest  relief,  frequently  diminishing  the  pulse 
and  entirely  relieving  the  pain  and  dyspnoea  in  a  few 
minutes.  Also,  where  the  temperature  is  high  and 
quinine  alone  fails,  the  above  measure  combined  with 
the  administration  of  qiiinicB  sulph.  grs.  xx-xxv.,  is 
followed  by  the  most  excellent  results. 

CHARITY    HOSPITAL. 

As  a  rule,  the  treatment  at  this  hospital  does  not 

materially    differ    from    that  adopted    at    Bellevue. 

The  following  is  used  as  an  anti-rheumatic : 

9.    Sodii  et  potass,   tart.  .          .        •  5  ss. 

Vini  colchici  sem.     .  .         .           3  ii- 

Aqu^  q.  s.  ad            .  .          .            §  ii. 
M.  Dose  :  A  teaspoonful. 

ST.  FRANCIS'    HOSPITAL. 
When  the  praecordial  pain  is  intense  and  resists 


l6o  PERICARDITIS'. 

Other  remedies,  Dr.  J.  H.  Ripley  often  finds  it 
yield  to  the  application  of  a  plaster  prepared  by 
dusting  chloral  hydrate  on  the  ordinary  picis  burgun- 
dicae,  previously  spread  on  a  suitable  piece  of  adhes- 
ive plaster.  The  salicylic  acid  treatment  is  employed 
by  him  as  follows  : 

5.    Acidi  salicylici         .  .  .  3  ii- 

Sodii  bicarb.  ...  3  iss. 

Aquae  ad         .  .  .  .  5  iv. 

M.    Sig.  A  tablespoonful  every  two  hours. 

MT.  SINAI    HOSPITAL. 

When  associated  with  rheumatism,  Dr.  Jacobi 
administers  salicylate  of  soda.  By  this  means  he 
controls  the  rheumatic  affection,  and,  with  the  occa- 
sional use  of  digitalis  and  morphia,  affords  relief  to 
the  praecordial  pain  and  distress.  In  some  instances 
he  also  uses  cold  in  the  shape  of  ice-bags  applied 
over  the  region  of  the  heart  to  allay  the  pain. 

ROOSEVELT   HOSPITAL. 

Salicylic  acid  is  also  prescribed  at  this  hospital,  as 
follows  : 

5--    Acid,  salicylic.         .         .         .       grs.  clx. 
Sodii  bicarb. 

Potass,  bicarb.         .         .         .  aa  3  ii- 

Syrup,  limonis        ...  5  i- 

Aquae  ad         ...         .  §  iv. 

M.     Dose:  A  tablespoonful  thrice  daily. 

Dr,  W,  Ht  Thomson  uses  the  following  combina- 


PERICARDITIS.  l6l 

tion,  a  favorite  with  him  also  in  his  service  at  Belle- 
vue  Hospital  : 

9.    Sol.  acidi  salicylic.         .         .         .        J  ii. 
Tinct.  gaultheriae  .         .         .  3  i- 

Aquae  ad      .         .         .  .  §  iv. 

M.    Dose  :  A  tablespoonful. 


HYDROPERICARDIUM. 


Definition.  —  A   preternatural   accumulation  of 
the  normal  serous  secretion  of  the  pericardium. 

BELLEVUE    HOSPITAL.       . 

Dr.  Alonzo  Clark  treats  this  condition  purely 

as  a  dropsy  elsewhere.     He  restricts  the  patient  in 

the  amount  of  fluids  taken,  and  administers  diuretics 

together  with  digitalis  for  its  effect  on  the  heart.    The 

following  is  usually  employed  by  him  : 

5.    Infus.  digitalis       .         .         .         .  5i- 

Potass,  acetat.       ...  3  ii-iv. 

Aquae  ad       .  .         .         .         .         5  h. 

M.    Dose  :  A  tablespoonful  thrice  daily. 

In  some  the  acetate  of  potassium  causes  vomiting, 

therefore  Dr.  Clark  prefers  the  following  as  a  more 

elegant  and  agreeable  mode  of  administration  : 

5.    Potass,  carbon.     .         .         .  grs.  xx. 

Aquae 5  ss. 

M.    et  add. 

Succ.  limon.  recent.  .         .  5ss. 

Sig.   Dose,  every  two  hours. 

With  this  he  also  gives  : 

5-.     Infus.  digitalis         .  .         .         .       3  ii' 

Sig.  Dose,  three  times  daily. 

162 


HYDROPERICARDIUM.  "  163 

Where  the  fluid  cannot  be  made  to  disappear,  and 
dyspnoea  is  intense,  paracentesis  is  resorted  to. 

Dr.  Loomis  especially  directs  his  treatment  to  the 
cause  of  the  effusion.  The  direct  means  employed 
are  similar  to  those  adopted  by  him  for  the  treatment 
of  hydrothorax. 


ENDOCARDITIS. 


Definition. — An  inflammation  of  the  membrane 
lining  the  interior  of  the  heart  and  its  cavities,  and 
covering  its  valves. 

NEW  YORK  HOSPITAL. 

The  treatment  at  this  hospital  consists  primarily 
in  absolute  rest  in  bed,  perfect  quiet,  and  avoidance 
of  all  excitement.  Occuring  in  rheumatic  fever,  Dr. 
W.  H.  Draper  administers  the  salicylic  acid  treat- 
ment as  in  pericarditis.  If  there  is  much  anaemia, 
iron  in  some  form  is  employed  ;  BlaucTs  pills  being 
very  serviceable.  Where  there  is  much  praecordial 
pain,  with  dyspnoea  and  palpitation,  he  gives  ext. 
quebracho  fl.,  in.  xx-xxx,  with  great  advantage.  If 
the  temperature  runs  high  and  prostration  is  marked, 
quinine  is  also  given,  combined  with  the  administra- 
tion of  stimulants  ;    thus  : 

Ti.     Spts.  vini  gall.         .         .         .  ^ss. 

Sig.  Dose,  every  two  or  three  hours. 

BELLEVUE  HOSPITAL. 

As  a  complication  of  rheumatism,  Dr.  AUSTIN 
Flint's  treatment   does   not   differ  materially  from 

164 


ENDOCARDITIS.  l6$ 

that  of  pericarditis.  Salicylate  of  soda  or  salicylic 
acid  is  used,  combined  with  the  administration  of 
the  alkalies. 

Under  similar  conditions,  Dr.  Alonzo  Clark 
also  employs  the  corresponding  treatment.  When, 
however,  endocarditis  is  recognized  as  occurring 
alone,  he  at  once  abstracts  blood  to  the  amount  of 
5  viii-x,  in  order  to  relieve  the  over-worked  valves. 
With  this  he  combines  the  use  of  opium  in  moderate 
doses,  sufficient  to  quiet  the  irritant  action  of  the 
heart.  Counter-irritation,  while  doing  no  harm,  he 
considers  entirely  useless. 

Dr.  Loomis  is  also  governed  in  his  treatment  by 
the  associate  condition.  If  rheumatism,  this  receives 
prompt  attention,  as  elsewhere  described.  The  fol- 
lowing is  one  of  Dr.  Loomis'  tonics  used  at  this 
hospital : 

5.    Sol.  quinise  sulph,  (grs.  xv-fl.  3  i)  §  ii. 

Tinct.  ferri  chlor.  .  .  .        §  ss. 

Spts.  chloroformi         .  .  .        3  vi.   ' 

Glycerinae  q.  s.  ad       .  .         .        J  iv. 

M.     Dose  :  A  teaspoonful. 

Occurring  with  blood-poisoning,  stimulants  are 
freely  used.  Coming  on  in  the  course  of  Bright's 
disease,  those  agents  which  hasten  the  elimination 
of  urea  are  employed.  Occurring  with  the  fevers, 
antipyretics  are  administered.  In  all  cases,  he  con- 
siders the  presence  of  endocarditis  a  demand  for 
prompt  and  energetic  treatment.  Rest  is  all  impor- 
tant, and  must  be  absolute.  For  this  purpose,  when 
required,    he    administers    opium,   but   in   moderate 


1 66  ENDOCARDITIS. 

doses.  Stimulants,  brandy  and  iron  are  also  given 
as  indicated,  and  the  diet  made  of  the  most  nutria 
tious  character  throughout.  If  the  heart  becomes 
feeble,  digitalis  is  employed.  As  regards  the  iodide 
of  potassium,  Dr.  Loomis  thinks  it  doubtful  whether 
there  is  any  benefit  derived  from  its  administration. 


HYPERTROPHY  OF  THE  HEART. 


Definition. — An  abnormal  growth  of  the  mus- 
cular fibres  of  the  heart,  causing  increase  in  bulk  of 
the  organ  by  thickening  its  parieties,  and  generally 
resultine  in  dilatation  of  its  cavities. 


'fc> 


BELLEVUE    HOSPITAL. 

Dr.  Loomis  directs  that  the  use  of  alcohol  must 
be  avoided,  and  every  intemperance  in  eating,  habits, 
and  exercise,  both  physical  and  mental,  be  carefully 
guarded  against.  Constipation  should  be  prevented 
by  regular  habits  and  diet,  and  cathartics  employed 
only  when  absolutely  necessary.  When  signs  of 
cerebral  oppression  are  prominent,  to  lessen  the 
force  of  the  heart's  action  he  places  most  reliance 
upon  the  use  of  aconite  in  full  doses ;  given  thus : 

9-     Tinct.  aconit.  rad.  (Fleming)     gtt.  ii-iii. 
Sig.  Dose,  every  three  or  four  hours. 

From  this  he  obtains  more  prompt  relief  from  the 
vertigo,  etc.,  than  by  any  other  means.  Digitalis  is, 
as  a  rule,  contra-indicated. 

167 


1 68  HYPERTROPHY   OF   THE   HEART. 

NEW  YORK    HOSPITAL. 

In  hypertrophy  with  dilatation,  with  weakened 
pulse  and  irregular  cardiac  action,  Dr.  W.  H.  Draper 
employs  digitalis  with  advantage,  strengthening  the 
force  of  the  heart  and  affording  great  relief.  When 
flatulence  is  present,  a  brisk  purge  is  given  with 
good  effect.  The  diet  is  made  nutritious  and  easily 
digestible. 

MT.  SINAI    HOSPITAL. 

In  children,  where  cardiac  hypertrophy  depends 
upon  a  chronic  bronchitis,  Dr.  JacoBI  aims  to 
diminish  and  to  cause  absorption  of  the  bronchial 
exudation,  thus  relieving  the  pulmonary  obstruction. 
To  accomplish  this  he  gives : 

9-    Potass,  iodidi         .         .         .       grs.  iii-v. 

Aquae  q.  s. 
M.    Sig.  Dose,  three  times  a  day,  after  meals. 


DILATATION  OF  THE  HEART. 


Definition. — An  enlargement  of  the  cavities  of 
the  heart,  attended  with  thinning  of  the  parietes  of 
the  organ  and  a  diminution  of  its  contractile  power. 

BELLEVUE  HOSPITAL. 

Dr.  Alonzo  Clark  directs  that  the  patient  ab- 
stain from  all  exercise,  and  that  everything  tending 
to  excite  the  heart's  action  be  most  carefully  avoided. 
He  enjoins  absolute  rest  and  quiet,  although  permit- 
ting the  patient  to  walk  about  the  room  at  times, 
when  so  disposed.  He  also  endeavors  to  enrich  the 
blood  and  delay  the  progress  of  the  disease  by  ad- 
ministering a  good,  nutritious  diet,  taken  frequently 
and  to  the  full  extent  of  digestion  ;  this  is  also  as- 
sisted by  the  use  of  chalybeates,  which  further  serve 
to  correct  the  anaemic  condition.  Digitalis  is  given 
in  doses  sufficient  to  control  the  irregularity  of  the 
heart.  Bleedings  for  the  relief  of  dyspncea,  is  never 
resorted  to  by  Dr.  Clark,  under  any  circumstances  ; 
he  considers  it  an  extremely  dangerous  procedure. 
For  the  oedema,  the  activity  of  the  kidneys  are  in- 
creased by  the  following : 

!p.     Infus.  digitalis 

Potass,  acetat.  .         ,         ,     aa  3  ii-iv. 

M.    Sig.   This  amount  daily, 

169 


I/O  DILATATION   OF   THE   HEART. 

If  the  patient  is  strong  and  able  to  bear  the  sweat- 
ing, he  often  employs  the  following  with  advantage  : 

^.     Tinct.  jaborandi         .         .  gtt.  xx. 

Aquae  q.  s. 

Sig.   Dose,  at  night. 

Simple  dilatation,  Dr.  Clark  believes  to  be  ex- 
tremely rare  ;  he  has  met  with  but  two  or  three  cases 
during  his  life. 

Dr.  Loomis'  treatment  is  directed  toward  sustain- 
ing the  nutrition  of  the  patient  and  regulating  the 
heart's  action.  For  the  former  he  prescribes  a  diet, 
nutritious  in  character,  often  consisting  entirely  of 
milk,  and  administered  frequently  in  small  amounts. 
In  certain  cases  he  also  combines  small  doses  of 
stimulants  with  the  food.  Iron  is  also  given,  as  a 
rule,  especially  when  the  patient  is  anaemic.  The 
following  is  used  at  this  hospital : 

9-.     Quiniae  sulph.  .  .  grs.xxx. 

Acid,  sulph.  dil.  .  .  q.  s. 

Aquae         ....  §  ii. 

Tinct.  ferri  chlor.        .  .  3  ii« 

M.    Dose  :  A  teaspoonful. 

Mildly  stimulating  baths  are  at  times  of  service  to 
keep  up  a  free  action  of  the  skin.  Abundance  of 
fresh  air  should  be  obtained,  and  careful  attention 
given  to  hygienic  regulations. 

To  fulfill  the  second  indication  Dr.  LoOMiS 
QniorcQS  absolute  rest  and  quiet,  observing  the  greatest 
care  in  avoiding  all  inordinate  exercise  or  undue  exer- 
tion of  any  kind.  He  also  resorts  to  various  medicinal 


DILATATION   OF   THE   HEART.  171 

agents,  such  as  may  be  required  by  the  special  con- 
ditions of  each  case.  The  mineral  acids  and  vegeta- 
ble tonics  are  employed,  when  indicated,  to  improve 
the  digestion  and  appetite.  The  following  is  from 
this  hospital  : 

]^.    Tinct.  cinchonae  co. 

Tinct.  gent.  co.  .  .  aaji. 

M.    Dose  :  A  teaspoonful. 

Where  systemic  congestions  are  present,  an  occa- 
sional purge  of  aloes  or  calomel  is  administered  with 
good  effect.  For  the  heart  he  finds  digitalis  most 
beneficial,  giving  it  in  sufficient  amount  to  control 
the  irregular  cardiac  action  ;  and  even  after  this  is 
secured,  the  drug  is  still  continued,  but  in  small 
doses.  When,  in  time,  digitalis  fails  to  exert  this 
effect,  he  finds  that  a  combination  of  opium  or  bella- 
donna with  digitalis  is  very  serviceable  temporarily. 
For  the  attacks  of  dyspnoea,  hydrocyanic  acid  is  often 
useful.     The  following  is  kept  constantly  on  hand : 

~^.    Potass,  cyanidi 

Morph.  sulph.  .  .         aa.  gr.  xvi. 

Syrup,  tolutan.         .  .  5  xvi. 

M.    Dose  :     A  teaspoonful. 

Or,  he  sometimes  resorts  to  counter-irritation  by 
means  of  dry  cups. 

In  all  cases,  the  course  of  the  dilatation  being  pro- 
longed over  a  considerable  time,  Dr.  Loomis  em- 
ploys numerous  remedies  and  means  demanded  in 
individual  instances  for  temporary  benefit,  but,  as  a 
rule,  he  relies  almost  solely  upon  digitalis  and  iron. 


1/2  DILATATION   OF   THE   HEART. 

ROOSEVELT  HOSPITAL. 

In  the  later  stages,  when  there  is  a  condition  of 
oedema  and  pleuritic  effusion,  with  dyspnoea,  album- 
inuria, and  possibly  symptoms  of  uraemic  poisoning, 
Dr.  W.  H.  Thomson  resorts  to  the  following  plan 
of  treatment.  Stimulants  are  administered  freely, 
together  with  : 

^.    Infus.  digitalis  .  .  .  3  ss. 

Potass,  acetat.  .  .         grs.  xv-xx. 

M.     Sig.  Dose. 
The  following  is  also  given  : 

9.     Ext.  jaborandi  fl.         .         ,         .         3  ss. 

Sig.     Dose,  at  night. 

If  the  bowels  are  constipated,  gtt.ii  of  croton  oil 
are  given  in  pill  form.  Should  these  means  fail  in 
effect,  with  semi-coma  approaching,  the  patient  is 
placed  in  the  hot-air  bath  and  enemata  of  whiskey, 
milk,  and  fluid  extract  of  jaborandi  administered. 
If  these  are  rejected,  and  the  stupor  increasing  with 
severe  dyspnoea,  Dr.  THOMSON  resorts  to  the  fol- 
lowing: the  surface  of  the  body  is  thoroughly  oiled, 
and  the  patient  then  wrapped  in  blankets  saturated 
with  hot  water  ;  he  also  gives  pilocarpine gr.  yV  hypo- 
dermically,  together  with  the  following  by  the  mouth  : 

J^.    Hydrarg.  chlor.  mit.  .  grs.  xv. 

Ext.  jalapae         .  .         .  grs.  x. 

Sig.     Dose. 

This  is  repeated  if  necessary.  By  either  or  all  of 
these  procedures  diaphoresis  is  usually  established, 


DILATATION   OF   THE   HEART.  1 73 

which,  if  moderate,  he  assists  by  the   continued  in- 
jections of  pilocarpine,  as  follows  : 

9.     Pilocarpine  .      *     .  .  gr.  J^. 

Sig.     Dose,  every  three  hours,  up  to  gr.  ss. 

If  the  bowels  refuse  to  move,  in  addition  to  the 
above  measures,  he  administers  gr.  -gV-jV  ^f  ^l(^i^'^'i^t^ 
every  hour  for  three  or  four  hours.  The  diet  is  of 
milk  and  lime  water,  together  with  soda  powders  and 
vichy  given  to  relieve  the  vomiting  when  present, 
and  alcoholic  stimulation  as  indicated.  This  regi- 
men is  usually  followed  by  very  satisfactory  results. 
Sometimes  dry  cups  are  also  applied  over  the  kid- 
neys. 


FATTY  DEGENERATION  OF  THE 

HEART. 


Definition. — A  change  occurring  in  the  muscu- 
lar structure  of  the  heart,  resulting  in  the  deposit  of 
fatty  molecules  replacing  the  primitive  filaments, 
and  converting  the  muscular  substance  into  fat. 

BELLEVUE  HOSPITAL. 

Dr.  Alonzo  Clark's  treatment  aims  at  causing 
absorption  of  the  fatty  material  and  reducing  the 
supply  of  fat  in  the  body.  He  instructs  the  patient 
to  take  what  moderate  exercise  he  can  endure,  accord- 
ing to  his  strength,  and  to  abstain  from  all  fattening 
foods  including  milk,  cream,  and  fat  of  meats.  The 
diet,  however,  he  requires  to  be  of  the  most  nutri- 
tious quality,  preferring  meats,  fowl,  etc.,  and  food 
made  from  wheaten  flour;  but  allowing  only  lean  meats 
and  the  vegetable  foods  that  contain  the  least  oily 
matter.  With  these  dietetic  measures  he  also  com- 
bines the  administration  of  the  bicarbonate  of  soda 
to  such  a  degree  as  it  will  be  safely  borne  and  pro- 
duce the  most  effect  upon  the  fatty  degeneration  ; 
this  he  judges  by  a  daily  examination  of  the  urine, 
which  he  requires  to  be  kept  in   the  slightest  degree 

174 


FATTY   DEGENERATION   OF   THE   HEART.       1 75 

acid.     Dr.  Clark  considiers  this  plan  well  worth  a 
trial,  although   he   thinks  it  doubtful  if  benefit  may- 
be derived  from  any  treatment. 

The  following  is  used  at  this  hospital : 

5..    Sodii  bicarb.         .  .         .         .  5  i. 

Tinct.  zingiber.    .      .   .         .         .    fl.  3  ii. 

Tinct.  gent.  co.    .         .  .   .      .     fl.  3  i. 

Aquae  .         .         .         .         .         .     fl.  5  v. 

M. 

Dr.  Loomis  endeavors  to  improve  the  tissue- 
making  power  of  the  blood  by  the  administration  of 
tonics,  iron,  and  cod  liver  oil,  with  good  food  and 
plenty  of  fresh  air.  All  over-exertion,  both  physi- 
cal and  mental,  tending  to  excite  the  heart's  action 
must  be  avoided,  and  rest  and  quiet  obtained.  Mod- 
erate stimulation  is  allowed,  but  the  habitual  or  exces- 
sive use  of  alcohol  is  prohibited.  By  careful  atten- 
tion to  these  measures  he  believes  that  life  may  often 
be  prolonged  for  many  years.  Digitalis  is  occasion- 
ally employed  w^hen  venous  congestion  is  prominent, 
otherwise  he  considers  it  of  little  or  no  value. 

Dr.  Austin  Flint  also  endeavors  to  place  the 
general  health  of  the  patient  in  the  best  possible 
condition,  and  to  improve  the  state  of  the  blood. 
This  he  accomplishes  by  proper  dietetic  regulations, 
by  the  use  of  chalybeates  if  required,  and  by  the 
adoption  of  the  necessary  hygienic  measures.  If 
any  unusual  weakness  of  the  heart  manifests  itself, 
he  derives  a  certain  amount  of  benefit  from  the 
administration  of  digitalis  as  a  cardiac  tonic ;  or,  at 
times,  he  employs  strychnine  and  fiux  vomica  for  this 


1/6       FATTY   DEGENERATION   OF   THE   HEART. 

purpose.  While  the  use  of  fatty  foods  are  not 
entirely  prohibited,  yet  he  considers  that  they  should 
be  restricted  within  certain  limits.  He  also  directs 
that  the  patient  take  such  exercise  as  is  compatible 
with  comfort;  beyond  this  limit  it  is  to  be  restricted. 
I^.    Tinct.  ferri  chlor. 


Quiniae  sulph. 

.       3  i-ii 

Strych.  sulph. 

.       gr.  i 

Syrup,  aurant.  flor. 

3iss 

Glycerinae    . 

.          .           5i 

Aquae  q.s.  ad. 

•         Siv 

M.  Dose  :  A  teaspoonful  three  times  daily,  before 
meals. 

The  above  is  an  excellent  combination  which  has 
been  used  very  extensively  at  this  hospital  by  a  for- 
mer house  physician. 


PALPITATION. 


Definition. — An  irregularity  of  the  heart's 
action,  during  which  the  pulsations  become  more 
pronounced,  usually  intermittent,  and  more  sensible  ; 
not  associated,  as  a  rule,  with  organic  trouble,  except, 
in  certain  instances,  more  or  less  hypertrophy  of  the 
organ. 

BELLEVUE  HOSPITAL. 

In  functional  disturbance  of  the  heart  Dr.  AUS- 
TIN Flint  directs  his  treatment  to  the  removal  of 
the  cause.  This  he  considers  to  be  of  primary 
importance.  If  dependent  upon  the  use  of  tobacco, 
tea  and  coffee,  alcohol,  etc.,  these  must  be  abandoned. 
Over-exercise,  prolonged  mental  anxiety,  excessive 
venery,  and  every  thing  tending  to  promote  dyspep- 
sia must  be  avoided.  He  administers  tonic  reme- 
dies and  a  good,  wholesome  diet  with,  in  certain 
cases,  a  little  wine.  When  anaemia  is  present  he 
prescribes  the  chalybeates,  with  good,  hygienic  meas- 
ures, a  change  of  scene,  if  practicable,  and  means  to 
improve  the  appetite  and  assimilation.  The  follow- 
ing is  from  this  hospital : 

12  177 


1/8 

PALPITATION. 

9. 

Ferri  phosphat. 

,          , 

grs.  ii. 

Quinise  sulph. 

. 

gr.  i. 

Strychniae  sulph. 

. 

gr-T2- 

Syrupi 

. 

3i. 

M. 

Sig.    Dose. 

Also: 

9. 

Acid,  muriat. 

. 

3iii. 

Tinct.  gent.  co. 

Aquae  ....       aajviii. 

M.      Dose :     A  teaspoonful. 

When  associated  with  organic  lesions,  Dr.  Flint 
advises  care  in  attaching  undue  importance  to  the 
organic  trouble,  simply  from  the  fact  of  a  coexist- 
ing functional  affection  ;  for  with  the  removal  of 
this  disturbance  the  organic  lesion  may  give  rise  to 
no  symptom  whatever. 

Dr.  Loomis  also  treats  the  primary  condition. 
Where  anaemia  is  marked  iron  is  employed  with 
benefit.  If  dependent  on  the  habitual  use  of  alco- 
hol, tobacco,  or  coffee  and  tea,  these  are  to  be  aban- 
doned. When  associated  with  the  gouty  diathesis, 
remedies  controlling  this  affection  are  resorted  to. 
Where  no  apparent  cause  is  ascertained,  he  prescribes 
a  cold  sp07tge-bath\.3kQ\\  night  and  morning,  combined 
with  mild  exercise,  a  plain  diet,  and  the  avoidance 
of  all  undue  exertion.  For  immediate  relief,  those 
drugs  which  act  specifically  on  the  nerve  centres  and 
the  diffusible  stimulants  are  usually  employed  with 
success.  DigitaliSj  he  advises,  should  never  be  used, 
and.  as  a  rule,  narcotics  are  considered  harmful. 


PALPITATION.  179 

Dr.  Alonzo  Clark  advises  moderation  in  all 
things,  avoiding  fast  eating  and  any  disorder  of 
digestion.  The  patient  should  never  eat  to  a  full 
stomach.  In  persistent  palpitation  without  organic 
disease,  with  a  marked  increase  in  the  impulse  of 
the  heart,  he  makes  use  of  the  following : 

9.    Tinct.  aconiti  rad.  .         .         .      gtt.  i. 

Aquae  q.  s. 

M.     Sig.     Dose,  three  times  daily. 

He  thus  maintains  the  continuous  effect  of  the 
drug,  sometimes  with  great  satisfaction.  In  other 
instances  where  the  hypertrophy  is  extensive  he  pre- 
fers veratrunt  viride,  in  doses  of  gtt.  i.  of  the  fluid 
extract,  diminishing  or  increasing  the  amount  accord- 
ing to  the  required  indications.  When  occurring  in 
a  strong,  robust  patient  with  sthenic  pulse,  Dr. 
Clark  often  performs  venensectioit  with  very  gratify- 
ing results,  bleeding  to  §  vi-x. 

In  palpitation  without  organic  lesion,  Dr.  E.  G. 
Janeway  aims  to  remove  the  cause  and  secure  rest, 
good  food,  change  of  scene,  and  entire  release  from 
care.  He  also  advises  that  the  various  functions 
must  be  carefully  attended  to,  and  any  local  disorder 
in  females  removed  by  suitable  treatment.  Where 
the  irregularity  and  palpitation  persists,  as  in  Graves* 
disease,  and  medical  treatment  is  without  avail.  Dr. 
Janeway  employs  the  galvanic  current  with  most 
beneficial  effects.  He  frequently  reduces  the  rapidity 
of  the  pulse  from  120  to  90  beats  in  a  very  few  min- 
utes, and  has  produced  a  cure  in  several  cases.  In 
applying  the  current  he   places  one  pole    over  the 


l8o  PALPITATION. 

back  of  the  neck,  the  other  over  the  sympathetic. 
This,  of  course,  by  its  contiguity  also  stimulates  the 
pneumogastric ;  and,  besides  acting  on  the  nervous- 
ness and  imagination  of  the  patient  by  this  method, 
which  he  finds  of  marked  value  in  these  cases,  Dr. 
Janeway  considers  that  it  is  this  stimulation  of  the 
pneumogastric,  and  not  of  the  sympathetic,  which 
affords  relief.  He  uses  the  constant  current,  apply- 
ing it  three  times  a  week,  first  to  one  side  of  the 
neck,  then  to  the  other.  This  treatment  he  also  sup- 
plements by  the  administration  of  the  iodide  of  iron, 
preferring  Blancard's  pills  (U.  S.  P.).  Another  plan 
sometimes  adopted  by  him  is  to  cause  the  patient  to 
take  a  number  of  long  breaths.  This  slows  the  heart, 
but  it  also  produces  dizziness. 

ST.  LUKE'S  HOSPITAL. 

Removal  of  the  exciting  cause  constitutes  the  chief 
element  in  the  treatment.  Where  dyspepsia  is  pres- 
ent Dr.  Beverley  Robinson  administers: 

IJ.    Tinct.  lavandulae  CO.  .         .  3  ss-i. 

Sig.  Dose, 
with  very  good  effect.  Or,  in  other  instances,  as  in 
hysterical  women,  spts.  ammon.  aromatic,  Zi-H-  will 
often  give  instant  relief.  When  painful  cardiac  sensa- 
tions are  present  with  loss  of  sleep  ;  or  if  slight  indul- 
gence in  smoking  makes  the  heart  seem  suddenly  to 
stop,  or  beat  forcibly  and  rapidly  and  then  intermit ; 
under  these  circumstances  he  advises  careful  attention 
to  hygiene  and  abundant  sleep  and  leisure.  Should  the 


PALPITATION.  l8l 

disturbance  still  persist,  he  enjoins  total  abstinence 
from  tea,  coffee  and  tobacco,  and  administers  moder- 
ate doses  of  henbane^  chloral  or  aconite,  combined 
with  the  local  application  of  a  belladonna-plaster  over 
the  praecordial  region.  These  measures,  he  finds, 
rarely  fail  to  bring  the  heart  into  regular  working 
order.  During  a  painful  attack  of  palpitation,  Dr. 
Robinson  sometimes  finds  it  necessary  to  give  an 
opiate  or  antispasmodic.  As  a  rule,  however,  he 
makes  use  of  the  following  prescription  with  the 
greatest  satisfaction  in  numerous  instances  : 

9-.    Tinct.  lavandulae 

Spts.  ammon.  aromat. 
^Etheris  chloric.         .         .         .       aa  §  i. 
Syrupi         .....  J  iii. 

M.  Dose :  A  teaspoonful  in  water  every  hour, 
till  relief. 

Where  there  is  much  weakness  accompanied  by 
fainting  sensations,  alcoholic  stimulants  are  employed 
with  benefit.  He  also  resorts  to  other  and  variable 
means  of  treatment,  according  to  the  requirements 
of  each  particular  case.  If  a  plethoric  state  is  pres- 
ent, mild  depletory  measures  are  used.  If  anaemia, 
iron  is  administered  combined  with  a  generous  diet, 
and  abundance  of  fresh  air.  In  dyspeptics,  stomachics 
are  employed  and  regular  meals  ordered,  together 
with  exercise,  horseback-riding,  etc.  Where  the  pal- 
pitation depends  on  a  gouty  diathesis,  the  potas- 
sium and  lithium  salts  are  his  sheet  anchors. 


1 82  PALPITATION. 

NEW  YORK  HOSPITAL. 

In  the  treatment  of  persistent  palpitation  with 
Graves'  disease,  Dr.  W.  H.  Draper  knows  of  no 
specific  remedy.  In  recumbency  some  unexplained 
effect  is  produced  which  increases  the  inhibitory 
action  of  the  pneumogastric  nerve,  and  the  pulsa- 
tions are  thus  reduced  from  ten  to  twenty  beats  a 
minute.  He  therefore  considers  rest  in  the  recumbent 
position  all  important,  and  in  some  cases  this  is 
resorted  to  by  artificial  means.  Occurring  in  the 
course  of  the  menopause,  he  thinks  something  may 
be  accomplished  by  equalizing  and  regulating  the 
circulation.  For  this  purpose  he  believes  digitalis 
to  be  a  remedy  of  great  value,  and  should  be  tried 
although  it  often  fails.  In  some  instances  Dr.  DRAPER 
obtains  marked  benefit  from  the  use  of  the  carbonate 
of  iron,  combined  with  the  administration  of  digitalis 
and  the  alkalies.  The  following  is  often  employed 
at  this  hospital : 

^.    Potass,  et  sodii  tart.       .         .         .         3  ii- 
Potass,  acetat. 
Syrup,  zingiber. 
Aquae 
M. 

He  also  recommends  the  admini 
7iicE  sulpJi.,  gr.  -jV  tJiree  times  daily.  Also  Fowler  s 
solution  with  some  degree  of  service.  He  mentions 
a  case  which  he  cured  (twenty  years  ago,  and  the 
patient  alive  to-day)  by  the  iodide  of  potassium  ;  but 
he  has  never  since  seen  so  much  good  result  from  its 


5i- 
5  i. 
;  iii. 


stration  of  strych- 


PALPITATION.  183 

administration,  although  in  many  instances  its  effects 
are  very  gratifying.  In  all  cases  iron  is  usually  given 
with  advantage ;  this  is  especially  so  in  the  palpita- 
tion of  young  persons,  where  he  finds  it  of  marked 
value. 

The  essential  feature  of  treatment,  however,  he 
considers  to  be  rest  and  quiet,  avoiding  all  disturb- 
ance of  the  heart,  and  regulating  the  circulation  with 
tonics,  iron,  quinine,  etc.  The  following  is  from  this 
hospital : 

5.    Ferri  et  ammon.  citr.  .         .  3  i- 

Tinct.  nucis.  vom.         .         .         .         3  ii- 
Tinct.  cinchonae  co.     .         .         .         §  iv. 

M.    Dose  :  A  teaspoonful. 

Where  these  various  measures  fail  and  all  medi- 
cinal remedies  are  unavailing,  and  the  symptoms  are 
evidently  permanent  and  progressive,  Dr.  Draper 
endeavors  to  palliate  the  suffering  by  means  of 
morphia,  by  stimulants,  and  by  the  use  of  quinine 
when  fever  is  present. 


ANGINA    PECTORIS. 


Definition. — An  affection  of  the  heart,  charac- 
terized by  sudden,  violent  pain  referred  to  the  prae- 
cordial  region,  or  about  the  sternum,  shooting  to  the 
neck  and  left  shoulder,  sometimes  to  the  arm,  and 
backward  to  the  scapula  ;  accompanied  by  dyspnoea, 
great  anxiety,  the  sense  of  suffocation,  and  a  dread 
of  impending  death. 

BELLEVUE    HOSPITAL. 

For  the  immediate  arrest  of  the  paroxysm.  Dr. 
Austin  Flint  uses  stimulants  more  or  less  freely, 
either  alcoholic  or  ethereal.  Of  the  latter  he  prefers 
Hoffman's  anodyne,  using  the  following  combination: 

5-    Spts.  aether,  co. 

Liq.  morph.  sulph.  (U.  S.  P.)  aa  §  i. 

M. 

Alcohol  he  gives  in  doses  to  produce  a  prompt  and 
distinct  impression,  usually  adding  a  few  drops  of 
laudanum,  or  paregoric  elixir,  with  advantage.  When 
a  decidedly  prompt  action  is  required,  he  places  most 
reliance  on  the  following : 

^.    Amyli  nitriti  .         .         .         gtt.  v. 

Sig.     To  be  inhaled  from  a  cloth  or  sponge. 

184 


ANGINA   PECTORIS.  1 85 

The  good  effect  is  almost  instantaneous,  and  Dr. 
Flint  prescribes  this  remedy  repeatedly.  Regarding 
the  coexistent  heart  disease,  his  treatment  is  essen- 
tially that  which  belongs  to  valvular  lesions  and 
enlargement. 

Dr.  Alonzo  Clark  finds  Hoffman  s  anodyne,  by 
relieving  the  accompanying  flatulence,  of  much  ser- 
vice, often  giving  relief  to  the  paroxysm,  although 
not  remedial. 

During  the  paroxysmal  attack,  Dr.  Loomis  has 
the  greatest  confidence  in  the  free  administration  of 
digitalis  combined  with  complete  rest.  He  has  very 
little  or  no  faith  in  the  diffusible  stimulants,  sedatives, 
and  antispasmodics,  and  objects  to  the  use  of  opium, 
chloroform,  and  amyl  nitrite.  In  the  interval  between 
the  attacks  he  directs  that  all  emotional  and  physical 
excitement  be  avoided,  and  everything  tending  to 
produce  flatulence  and  indigestion,  thus  disturbing 
the  heart's  action,  be  carefully  prevented.  Medicin- 
ally, the  only  prophylactic  agents  upon  which  he 
places  any  reliance  are  iron,  arsenic,  and  strychnia, 
given  daily  in  small  doses.  By  this  means  he  not 
infrequently  succeeds  in  postponing  and  lessening  ^ 
the  severity  of  the  paroxysms.  The  following  is  an 
excellent  combination,  much  used  at  this  hospital : 

9.    Tinct.  ferri  chlor. 

Tinct.  nucis.  vom.       .         .  aa  m.  x. 

Aquae  q.  s.  ad     .  .  .  .  3  i. 

M.    Sig.  Dose,  three  times  daily,  after  meals. 


1 86  ANGINA   PECTORIS. 

NEW   YORK    HOSPITAL. 

Dr.  W.  H.  Draper  prescribes  a  course  of  treat- 
ment which  is  both  prophylactic  and  for  the  cure  of 
the  disease  itself.  The  medicinal  treatment  he  re- 
quires to  be  stimulating.  For  this  purpose  he 
employs  alcoJwl^  aniyl  nitrite^  and  morphine  hypoder- 
mically.  Of  these  he  considers  the  injections  of 
morphia  of  greatest  service,  as,  besides  acting  as  a 
stimulus  in  small  doses,  its  effects  last  longer  than 
alcohol.  He  also  places  much  reliance  on  the 
following  : 

9,    Amyl.  nitriti         .         .         .         gtt.  iii-v. 
Sig.     Dose,  by  inhalation. 

For  the  dyspnoea,he  often  gives  m.xx-xxx.  of  the 
fluid  extract  of  qiiebracJw^  and  frequently  with  excel- 
lent results.  Dr.  Draper  further  strictly  enjoins 
that  the  patient  be  put  to  bed,  kept  quiet  and  at 
rest.  This  he  believes  to  be  of  vital  importance, 
requiring  the  greatest  attention,  and  must  be  rigidly 
enforced. 

To  prevent  recurrence  of  the  attacks  he  advises 
care  and  attention  on  the  part  of  the  patient  to  the 
cardiac  lesion  (which  is  present,  as  a  rule).  He  cau- 
tions against  the  abuse  of  stimulants,  alcohol  and 
tobacco,  aiid  against  excitement  or  emotion  of  any 
kind.  For  the  flatulent  dyspepsia,  which  is  so  often 
a  troublesome  feature,  he  confines  the  patient  to  a 
simple  diet  ;  this  should  not  be  neglected.  Besides 
these  measures,  he  has  resort  to  other  means  of  treat- 


ANGINA   PECTORIS.  1 8/ 

ment,  such  as  heart  tonics,  etc.,  in  various  instances, 
when  in  his  judgment  they  are  required. 

When    angina   pectoris    occurs    without    organic 
lesion,  he  considers  it  as  a  case  of  ordinary  neuralgia 
and  treats  accordingly  ;  giving  iron,  arsenic,  strychnia, 
cod-liver  oil,  and  plenty  of  out-door  exercise,  with  a 
good  nutritious  diet ;  or  any  good  nerve  tonic.     The 
following  are  from  this  hospital : 

]^.    Ol.  morrhuae.        .         .         .         .         Jvi. 

01.  anisi       .         .         .         ...         3  ss. 

01.  sassafras.         ....     gtt.  x. 

Liq.  calc.  sacchar.         .         .         .  §  ii. 

M. 

(Not  compatible  with  acids.) 
^.    Acidi  arseniosi         .  .  .  gr.^. 

Ferri  et  quin.  citr.  .         .  .   grs.  Ixxx. 

Tinct.  cinch,  co.      ...  ^  ii. 

M. 


ANEURISM  OF  THE  AORTA. 


Definition. — A  spontaneous  dilatation,  incom- 
plete and  more  or  less  distinctly  circumscribed,  of 
some  part  of  the  aorta,  resulting  from  injury  or  dis- 
ease of  the  arterial  wall. 

BELLEVUE    HOSPITAL. 

Dr.  Loomis  requires  that  the  patient  have  abso- 
lute rest  in  bed  in  the  recumbent  position  ;  that  all 
unnecessary  movements,  mental  excitement,  and 
everything  stimulating  the  force  of  the  cardiac  action, 
be  rigidly  avoided.  To  this  he  adds  a  concentrated, 
nutritious,  and  well-regulated  diet,  which  at  the  same 
time  is  diminished  in  amount.  In  regards  to  Tuf- 
nell's  restricted  rest  and  dietetic  plan  of  treatment. 
Dr.  Loomis  does  not  favor  it.  For  internal  medi- 
cation he  prefers  iodide  of  potassium  and  ergot,  as 
rendering  by  far  the  most  valuable  assistance  in  the 
formation  of  a  coagulum,  as  well  as  in  arresting  the 
progress  and  allaying  many  of  the  distressing  symp- 
toms. For  the  intense  pain  he  gives  morphia  hypo- 
dermically.  This  he  finds  not  only  affords  relief,  but 
also  by  regulating  the  cardiac  movement  it  hinders 
the  aneurismal  growth,and  by  lessening  the  irritability 

i88 


ANEURISM   OF   THE   AORTA.  1 89 

and  restlessness  of  the  patient  it  gives  ease  and  quiet, 
which  are  so  necessary  to  the  treatment.  Bella- 
donna is  also  used  locally  for  temporary  relief.  When 
the  tumor  is  prominent,  the  constant  application  of 
an  ice-bag  is  sometimes  a  source  of  much  benefit  in 
allaying  the  pain,  besides  diminishing  the  superficial 
inflammation  and,  he  thinks,  possibly  assisting  in 
formation  of  the  clot.  Caution  is,  however,  advised 
against  a  too  long  continued  application. 

Regarding  the  surgical  treatment  of  aortic  aneur- 
ism, Dr.  LoOMis  looks  with  danger  upon  the  injec- 
tion into  the  sac  of  coagulating  liquids.  Galvano- 
puncture  and  the  permanent  introduction  of  wire  or 
cat-gut  he  also  discountenances.  Several  acupunc- 
ture needles  introduced  temporarily  and  retained  for 
a  day  or  two,  he  considers  a  less  dangerous  proced- 
ure, and  thinks  it  might  be  tried  with  safety.  But 
in  certain  cases,  that  is  to  say,  when  the  aneurism  is 
limited  to  the  arch  or  includes  the  left  carotid,  he 
believes  that  ligation  of  the  left  carotid  artery  offers 
the  greatest  hope  of  success. 

Dr.  Austin  Flint  places  the  patient  upon  a  good 
nutritious  diet,  with  absolute  rest  maintained  in  bed. 
While  he  does  not  favor  Tufnell's  rigid  regulations, 
yet,  in  some  instances,  he  enjoins  absolute  rest  for  a 
number  of  months,  combined  with  a  diet  which  is 
simple,  strictly  nutritious,  and  sufficient  for  the  wants 
of  the  system,  but  nothing  beyond.  For  internal 
medication,  he  gives  : 

5.    Potass,  iodidi         .         .         .       grs.  x-xv. 

Sig.     Dose,  three  times  daily. 


igo  ANEURISM   OF  THE  AORTA. 

This  he  considers  an  exceedingly  valuable  remedy 
in  many  cases.  Commencing  at  once  the  systematic 
use  of  the  drug,  he  gradually  increases  it  up  to  the 
point  of  comfortable  tolerance  (which  Dr.  Flint 
insists  is  essential  to  the  treatment),  and  continues 
the  administration  for  a  considerable  period  of  time. 
By  this  means,  in  certain  cases,  marvelous  results 
have  obtained.  He  has  freq.uently  seen  the  beneficial 
effect  of  this  remedy,  not  only  in  relieving  the  pain, 
distress  and  other  symptoms,  but  also  in  the  marked 
diminution  of  the  aneurismal  sac.  Even  where  the 
suffering  is  intense,  with  oedema  of  the  extremities 
and  dyspnoea  so  severe  that  the  patient  is  unable  to 
assume  the  recumbent  postion,  under  the  administra- 
tion of  iodide  of  potassium  Dr.  Flint  has  observed 
amelioration  of  all  the  symptoms  and,  indeed,  appar- 
ent recovery  seemed  to  follow. 

When  dyspnoea  and  cough  are  prominent,  and  for 
the  distressing  pain  caused  by  pressure  of  the  tumor, 
he  gives  small  hypodermic  injections  of  viorpJiia. 
Quebracho  is  often  used  with  great  advantage  in 
relieving  the  dyspnoea.  In  certain  instances  where 
potassium  iodide  has  been  given  up  to  iodism  with- 
out avail.  Dr.  Flint  has  prescribed  : 

I^.    Ext.  quebracho  fl.  .  .         .        3  ss. 

Sig.     Dose, 
with  almost  immediate  and  complete  relief,  lowering 
the  pulse  and  respiration  to  the  normal. 

Dr.  Alonzo  Clark  directs  that  the  patient  be 
kept  as  quiet  as  possible,  free  from  every  manner  of 
excitement,  with   rest  in   bed  for  a  period  of  several 


ANEURISM   OF   THE   AORTA.  IQt 

months.  He  also  prescribes  a  moderate  diet,  giving 
solid  food  in  the  smallest  amount.  Combined  with 
these  measures  he  orders potassiiun  iodide, grs.  x.  three 
times  daily.  This  administration  he  continues  for  a 
term  of  weeks  or  months.  For  the  relief  of  the 
intense  pain  produced  by  pressure  of  the  aneurismal 
sac,  Dr.  Clark  applies  an  opium-plaster  to  the  chest 
with  very  gratifying  effect. 

At  this  hospital  it  is  strongly  advised  by  one  of 
the  visiting  physicians  that  two  doses  ot  opium  should 
never  be  given  at  shorter  intervals  than  one  and  a 
half  or  two  hours.  This  rule  he  considers  of  grave 
importance.  Where  it  has  been  disregarded,  he  has 
seen  disastrous  results  follow  from  the  sudden  and 
apparently  cumulative  action  of  the  drug. 

NEW  YORK   HOSPITAL. 

Dr.  W.  H.  Draper  does  not  consider  treatment 
very  hopeful  under  any  circumstances.  Complete  rest 
is  a  desirable  factor,  as  it  diminishes  the  force  of  the 
circulation  and  assists  in  the  formation  of  the  coagu- 
lum.  This  he  enforces.  Of  the  drugs,  he  regards 
the  iodide  of  potassium  as  a  remedy  of  great  value. 
Digitalis  is  also  used,  thus  lessening  the  frequency 
of  the  cardiac  contractions ;  except  where  there  are 
symptoms  of  vertigo,  dizziness,  etc.,  indicating  aortic 
regurgitation.  For  the  pain,  morphia  is  given  hypo- 
dermically.  The  following  solution  is  usually 
employed  at  this  hospital  : 


r 


192  ANEURISM   OF  THE  AORTA. 

9 .    Morphiae  sulph.  .         .         grs.  Ixxx. 

Aquae  destil.  carbol.    .         .  fl.  5  v. 

M.     et  filt. 

When  there  is  a  condition  of  unusual  excitement 
and  restlessness,  followed  by  syncope,  whiskey  and 
digitalis  are  administered. 

In  aneurism  of  syphilitic  origin.  Dr.  Draper  has 
found  great  benefit  derive  from  the  use  of  potassium 
iodide,  often  relieving  the  dyspnoea,  pain  and  the  ac- 
companying symptoms  of  distress.  He  considers  it 
probable,  however,  especially  in  cases  of  cure,  that 
the  lesion  has  been  a  gummy  tumor  pressing  upon 
the  aorta,  instead  of  an  aneurism. 

In  such  instances  the  following  prescriptions  from 
this  hospital  may  be  found  very  serviceable : 

]^.    Hydrarg.  bichlor.         .         .         •        g^  i- 
Potass,  iodid.       .         .         .         .  3  ii- 

Tinct.  cardam.  co.        . 
Tinct.  gentian.  .         .         .       aa^i. 

M.     Dose  :  A  teaspoonful. 

Or: 

9.    Hydrarg.  biniod.  .         .         .       gr.  ss. 

Potass,  iodidi       .         .         .         .  3  !• 

Syr.  sarsaparil.  co.       .         .         .  §  i. 

M.    Dose  :     A  teaspoonful  three  times  a  day. 

Dr.  C.  E.  Hackley  orders  a  diet  of  light  and 
easily  digested  food,  the  avoidance  of  all  excitement, 
and  the  bowels  kept  open  by  laxatives.  The  follow- 
ing mixture  is  kept  constantly  on  hand: 


ANEURISM   OF  THE  AORTA. 


193 


5.    Sodii  et  potass,  tart.  .  grs.  cmlx.  • 

Ferri  et  potass,  tart.  .  grs.  cccxx. 

Aquae  menth.  pip.  .  fl.  3  iv. 

Aquae  q.  s.  ad.  .         .  Oi. 

Under  this  treatment  the  dyspeptic  symptoms  are 
usually  controlled  and  the  pain  considerably  lessened, 
thus  affording  great  relief  and  comfort. 

In  some  cases  TiifiielVs  plan  of  treatment  is  re- 
sorted to.  This  consists  in  placing  the  patient  in 
bed,  with  absolute  rest  in  the  recumbent  position 
enforced.  The  diet  is  of  the  most  restricted  quality, 
especially  the  fluid  portion,  and  made  up  as  follows : 

Breakfast — Bread  and  butter 

Cocoa  or  milk 
Dinner Meat,  boiled  or  broiled 

Potatoes  or  bread 


Supper- 


Water  or  light  claret 
-Bread  and  butter 
Milk 


3  11- 

§  iii. 
§  iii. 
1  iv. 

5  ii. 

^  ii. 


The  object  of  this  treatment  is,  {ci)  by  rest  and 
avoidance  of  all  muscular  exertion  to  lessen  the 
number  and  force  of  the  cardiac  movements,  and  thus 
slow  the  current  of  blood  ;  {h)  by  restricting  the  fluid 
portion  of  the  food  to  a  minimum  to  increase  the 
fibrinous  element  of  the  blood.  Hence  favoring  the 
formation  and  deposit  of  those  layers  of  fibrin  within 
the  sac,  which  is  the  first  step  in  the  curative  process. 
Dr.  Hackley's  observations,  post  mortem,  certainly 
go  to  show  that  this  treatment  is  to  a  certain  extent 
effectual ;  nevertheless,  the  excellent  results  claimed 


194  ANEURISM   OF  THE  AORTA. 

for  it  abroad  have  not  been  realized  in  this  country. 
Dr.  T.  M.  Markoe  recommends  the  following  plan 
by  which  he  has  observed  some  very  promising  re- 
sults. Indeed,  in  favorable  cases,  he  has  sometimes 
succeeded  in  curing  aneurism.  Rigid  observance  is, 
however,  required.  He  directs  that  the  patient  have 
complete  rest  in  bed,  with  perfect  quiet  and  freedom 
from  all  excitable  causes,  and  every  unnecessary 
movement  avoided.  His  treatment  then  consists  in 
diminishing  the  amount  of  the  diet  in  such  a  manner 
that,  although  it  shall  be  nutritious,  yet  the  quantity 
shall  be  very  small.  The  amount  of  fluid  is  also 
restricted  to  a  minimum.  In  addition  to  these  meas- 
ures, he  also  advises  the  administration  of  those 
remedies  which  increase  the  plasticity  and  tone  of 
the  blood.  The  anaemia,  which  is  usually  present  is, 
as  a  rule,  progressive.  This  is  to  be  cared  for  by  the 
appropriate  means.  He  may  also  resort  to  the  admin- 
istration of  potassium  iodide,  the  iodide  of  iron,  and 
the  citrate  of  iron  and  quinine.  The  following  is  an 
excellent  combination : 

^.     Ferri  et  quiniae  citrat.      .  .     grs.  Ixiv. 

Tinct.  aurant.  amar.         .         .         fl.  3  ii- 
Elix.  simplicis  .         .         .  fl.  3  i- 

Vini  xerici       .         .         .         .  fl.  5  ii- 

Aquae  q.  s.  ad  .         .         .        fl.  3  iv. 

M. 

ROOSEVELT  HOSPITAL. 

Dr.  Francis  Delafield  administers  potassium 
iodide  in  doses  determined  by  its  effect  on  the  heart. 


ANEURISM   OF   THE   AORTA.  I95 

This  he  continues  for  a  considerable  period  of  time. 
In  some  instances,  at  this  hospital,  when  the  tumor 
is  prominent,  strapping  is  applied,  and  found  to  be 
very  serviceable,  not  only  in  lessening  the  size  of  the 
tumor,  but  also  by  diminishing  the  pain  and  affording 
great  temporary  relief.  This  measure  is  also  supple- 
mented by  the  use  of  potassium  iodide. 

ST.  LUKE'S  HOSPITAL. 

Quebracho  is  employed  by  Dr.  G.  G.  Wheelock 
with  great  advantage  in  the  dyspnoea  attending 
aneurism  ;  given  thus  : 

]^.    Ext.  quebracho  fl.         .         .    m.  xx-3ss. 
Sig.   Dose,  three  times  daily. 

He  has  often  found  this  drug  serviceable  when  all 
other  remedies  have  failed. 

PRESBYTERIAN    HOSPITAL. 

For  the  dyspnoea  Dr.  A.  H.  SMITH  gives  fluid 
extract  of  quebracho,  in.  xx-xl,  and  frequently  with 
entire  relief. 

In  regard  to  ligation  of  the  carotids  for  aneurism 
occurring  near  the  heart,  Dr.  John  A.  Wyeth's 
conclusions,  based  on  clinical  experience,  are  of. 
great  importance.  Of  eight  cases  involving  the 
aorta  alone,  the  left  carotid  was  ligated  in  six  and 
all  recovered  with  improvement  ;  the  right  carotid 
was  tied  in  the  remaining  two  cases,  one  of  which 
died,  the  other  recovered.  For  aneurism  involving 
the  innominate  and  aorta,  the  ligature  was  applied 


196  ANEURISM    OF   THE  AORTA. 

to  the  right  carotid  in  five  instances,  all  fatal  ;  to  the 
left  carotid  in  two  cases,  one  fatal  and  one  recovered 
with  improvement.  Where  the  innominate  alone 
was  implicated,  of  nine  cases  in  which  the  right  caro- 
tid, was  tied,  six  died  and  three  recovered  (two  of 
these  dying  later).  Of  six  cases  in  which  the  innom- 
inate and  one  or  both  of  its  branches  were  involved, 
and  the  ligature  was  applied  to  the  right  carotid, 
four  proved  fatal.  For  aneurisms  of  the  carotid  alone, 
the  right  was  tied  in  five  instances  with  one  death  ; 
the  left  carotid  in  two  instances  with  one  fatal  ter- 
mination. 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

\ 

C28(ll49)  100M 

fiC941 
Goodwin 
Treatment   of  di 


G63 
1883 


and 


lnns^~L^^'^'  °^  the  heart 


